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10436050-DS-6 | 1,866 | ## HISTORY OF PRESENT ILLNESS:
Per night float admission, yo male with hypertension,
hyperlipidemia, history of MI, and recent intraparenchymal
hemorrhage suspected secondary to amyloid angiopathy. On
patient fell in bathroom, was taken to and
found to have a right temporal parietal bleed. He remained
stable and was d/c'd to rehab on with residual left-sided
weakness and was initially doing well. He then complained of
weakness and poor PO, was noted to be hypotensive 82/38 and so
he was brought to where his SBPs were apparently
in the and came up with 3L IV fluids. They did a CT of the
head which showed an acute right parietal hemorrhage around the
site of an old bleed and he was thus transferred to for
further management.
.
At , he was thought initially to have suffered stroke as
his course was not known. However, when radiology
reviewed the CT head with the CT from , findings actually
improved. He was admitted to the neuro ICU for concern for head
bleed.
.
In the neuro ICU, he was found to be dehydrated with acute renal
failure and a urinary tract infection. He received IV
ceftriaxone and vancomycin which was then switched to Cipro. He
remained afebrile without decreasing leukocytosis (15 down to
12). With IVF, his renal function improved from 2.9 to 2.4
(baseline is 1.4) and his SBP remained in the . ECHO showed
EF of 55%.
.
Neurologically, he had left sided weakness, mostly of distal
limb muscles which the patient felt was stable to improved since
his initial hemorrhage. He had increased tone in the legs,
upgoing toes but absent knee and ankle jerks. He continued to
have an old tremor of the right arm/leg which is worse with
movement. He is alert, oriented x3 with good attention. MRI done
today showed unchanged right temportal parietal bleed, no new
hemmorhage or shift.
.
Also of note, he has a right groin hematoma secondary to the
attempted placement of a femoral line at the outside hospital.
## MEDICAL HISTORY:
- Hypertension
- Hyperlipidemia
- CAD s/p MI
- Macular degeneration
- Hard of hearing, has hearing aides but doesn't wear them
- Right sided tremor x years
- Hx hip fracture (left) and chronic pain.
- PUD, s/p gastrectomy
- Appendectomy as a child
## GENERAL:
Awake, alert, responding appropriately, AxOx3.
## HEENT:
PERRL. EOMI. Poor dentition. No lesions noted.
in oropharynx, neck Supple, no carotid bruits
## CV:
Distant heart sounds, rrr, no murmur.
## PULMONARY:
Lungs clear to auscultation bilaterally
## ABDOMEN:
soft, non-tender, normoactive bowel sounds, palpable
liver edge 2cm below RCM.
## EXTREMITIES:
1+ radial, DP pulses bilaterally.
## SKIN:
PVD changes of the lower extremities bilaterally.
## NEUROLOGIC:
Alert, oriented x 3. Speech was not dysarthric. The
pt. had good knowledge of current events. CN2-12 grossly intact.
diminished bulk and increased tone throughout upper and lower
extremities. Tremor of the right arm and right leg at rest and
worse with motion. Decreased sensation in LUE compared to the
right. Decreased strength in the LLE compared to the right. Pain
in left hip limited exam. Gait deferred.
## IMPRESSION:
Allowing for differences in patient positioning, no
change in the mixed density right frontoparietal
acute-to-subacute intraparenchymal
hemorrhage with mass effect on the right ventricle and subjacent
sulci. No
evidence of herniation or new hemorrhage.
## ECHO:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. with normal free
wall contractility. The diameters of aorta at the sinus,
ascending and arch levels are normal. The number of aortic valve
leaflets cannot be determined. There is no aortic valve
stenosis. No aortic regurgitation is seen. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
## IMPRESSION:
Normal global biventricular systolic function. Mild
pulmonary hypertension. Limited study.
## IMPRESSION:
Right temporoparietal mixed intensity hematoma with
surrounding mass effect and edema, unchanged since the recent
study of . No new hemorrhage or shift of midline
structures is detected. Administration of Gadolinium contrast
may help identify the etiology of hemorrhage such as underlying
neoplasms or AV malformations.
## BRIEF HOSPITAL COURSE:
Mr. was admitted to neurology ICU for evaluation and care
of head bleed as well as for presumptive sepsis secondary to
urinary tract infection. The neurology ICU did the following:
Neuro
He was frequently monitered Q2 H for neuro checks. He underwent
CT scan of head. We called the neuroradiology room and
discussed with them about the CT scan findings from the previous
admission and it appeared that there was no area concerning for
acute bleed. It appeared that the size of bleed had decreased as
compared to the CT scan 2 weeks ago. The worsened weakness on
the left side was attributed to the urinary tract infection.
ID
He was found to have a urinary tract infection. He had
hypotension, and so fluids were given for treatment of
hypotension. Care was taken not to give him too agressive fluids
as that may lead to increase in the intracerebral edema. He was
started on ciprofloxacin.
Renal
He was noted to have acute renal failure. The baseline
creatinine as discussed with the office was found to be 1.4.
The reason was thought to be due to dehydration and UTI.
Medicine
Due to complex medical issues, it was felt that he may be better
served on medicine floor as opposed to neuromed floor. Medicine
was consulted and addressed the following problems:
## # ALTERED MENTAL STATUS:
Patient was AAOx3 during wntire stay on
medicine floor.
Possible causes of his episode of AMS included (a) Seizure: Per
neuro recommendation, seizure prophylaxis was Keppra 750 mg BID.
(b) Hypotension, see below. (c) IPH, see below. (d) UTI, see
below (e) Uremia, see below.
# Recent intraparenchymal hemorrhage: Per neuro, MRI and CT
scans appear to be stable/improving since initial insult on
. Per patient, he was initially getting stronger at rehab
but feels like this has set him back to where he was prior to
starting rehab with his left sided weakness. This worsening
appears to be due to weakness from hypotension and poor PO
intake, which have now resolved.
Hold anticoagulants (except SC heparin and ASA). Control BP (SBP
< 160).
.
# UTI: Urine culture showed E coli, resistant to ciprofloxacin.
Foley catheter removed. Ciprofloxacin therapy had to be changed
to cefpodoxime therapy, which will be continued for 7 days.
.
# Anemia: Followed CBC with tranfusion parameter set at
hematocrit < 25. Hematocrit was stable during hospital stay.
.
# Groin hematoma, secondary to attempted femoral line placement:
Remained stable in appearance during stay on medicine floor. CBC
was followed.
.
# Hypotension, resolved following IVF: Upon first transfer, SBP
was 90-120s in early morning of , but had recovered to
120s-130s in late morning. Blood pressure recovered to above
baseline, so hypertension therapy was initiated. See below.
.
# Acute Renal Failure, resolved: Likely secondary to
hypotension, improved with fluids. Good UOP. The patient was
below his baseline creatinine by his first morning on the
medicine floor, and his BUN/Cr improved every day thereafter.
.
# Atypical chest pain: On the second to last day of his hospital
admission, the patient complained of localized chest pain on the
left, mid-clavicular, approximately 8th rib. Presentation was
suggestive of musculoskeletal pain and was reproducible. EKG
showed no changes in comparison to EKG from . Cardiac
enzymes negative. Patient reported some relief after Percocet.
Presumed musculoskeletal.
# CAD s/p MI : ECHO 55% here, no previous records. Patient
does not believe he has any stents. Home simvastatin therapy was
continued. Aspirin therapy was initiated.
.
# Hyperlipidemia: Continued simvastatin therapy.
.
# Hypertension: Amlodipine therapy instituted to keep SBP < 160,
due to intraparenchymal hemorrhage. Metoprolol was slowly
restarted until we returned to his original home dose.
.
# Depression: Continued Celexa therapy from home regimen.
.
# Chronic hip pain: Continued Neurontin (currently renally
dosed) and Percocet, both from home regiman, as needed.
.
# GERD and history of PUD:
- Continued home Protonix therapy from home regimen.
.
# Chronic Nausea:
- Continued patient's home regimen as necessary.
.
# B12 deficiency:
- Continue outpatient B12.
## MEDICATIONS ON ADMISSION:
Neurontin 100mg TID (new)
Celexa 10mg (new)
Percocet q6 PRN
Zocor 80mg qday
Compazine 10mg Q6 PRN nausea
Calcium 600mg + Vit D BID
Vitamin B12 1000mg daily
Isosorbide Mononitrate 0mg daily
Lisinopril 5mg daily
Magnesium oxide 400mg daily
Colace 200mg PO BID
Metoprolol XL 100mg daily
Multivitamin daily
Protonix 40mg Daily
## DISCHARGE MEDICATIONS:
1. Simvastatin 40 mg Tablet
## SIG:
Two (2) Tablet PO DAILY
(Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
3. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
## 5. MULTIVITAMIN TABLET SIG:
One (1) Tablet PO DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO three times
a day.
8. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Prochlorperazine Maleate 5 mg Tablet Sig: Two (2) Tablet PO
Q6H (every 6 hours) as needed for nausea.
10. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 6 days.
Disp:*11 Tablet(s)* Refills:*0*
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
13. Levetiracetam 750 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
14. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
## 15. OXYCODONE-ACETAMINOPHEN MG TABLET SIG:
One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
16. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
## SIG:
One (1) Tablet Sustained Release 24 hr PO once a day.
## DISCHARGE DIAGNOSIS:
PRIMARY
Likely sepsis due to urinary tract infection
History of recent intraparenchymal brain hemorrhage with
cerebral edema
SECONDARY
Anemia
Groin hematoma
Acute renal failure
Hypertension
Hyperlipidemia
Coronary artery disease
Peptic ulcer disease
Gastroesophageal reflux disease
Depression
Chronic hip pain
Chronic nausea
B-12 deficiency
## DISCHARGE INSTRUCTIONS:
Mr. ,
It was a pleasure meeting you and treating you at
. You were brought to the hospital because you
were feeling weak and confused and because your blood pressure
was low. We think that your weakness, confusion, and low blood
pressure were caused by an infection. We have started you on
antibiotics that you can take in pill form with your other
medications. You will need to continue to take these antibiotics
for five more days at the rehabilitation facility.
We also took some pictures of your brain with our imaging
machines. Those pictures showed us that you did not have another
stroke. Your first stroke looks better on the pictures so far.
We hope that you continue to get stronger on your left side as
you work at the rehabilitation center.
START levetiracetam as directed.
START aspirin as directed.
START cefpodoxime as directed. Take for 6 days.
Again, we enjoyed caring for you at
.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10436050", "visit_id": "27209033", "time": "2113-01-02 00:00:00"} |
12255097-RR-30 | 148 | ## EXAMINATION:
Lower extremity graft duplex US.
## INDICATION:
year old man with h/o R fem-pop w/ PTFE and R pop-AT w/ vein
bypass, now s/p R fem endart with poor signals along graft// eval graft
patency, inflow, Please look at the proximal anastomosis, assess for possible
fluid collection ?hematoma
## FINDINGS:
The common femoral artery is patent with a velocity of 41 centimeters/second.
The area was difficult to evaluate due to staples in place. There is evidence
of an occluded right fem-pop bypass. There is evidence of a second bypass
from the popliteal to the ankle level. Is patent. The native proximal
velocity is 11 cm/sec. Graft velocities range from 8-39 cm/sec. The distal
anastomotic velocity is 6 cm/sec.
## IMPRESSION:
Patent common femoral artery with occluded fem-pop bypass graft. Patent pop
tib bypass graft with low velocities.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12255097", "visit_id": "20213436", "time": "2194-08-10 13:46:00"} |
19096902-RR-7 | 133 | ## INDICATION:
Right homonymous hemianopsia. Evaluate for stroke.
## FINDINGS:
There is acute to early subacute left PCA distribution infarction involving
medial and posterior left temporal lobe and left occipital lobe with
associated FLAIR hyperintensity. There is no evidence of hemorrhage.
There is a right middle cranial fossa, measuring 4.2 x 2.9 cm extending along
the right frontal convexity. The ventricles are normal in size without
midline shift. There is mild paranasal sinus disease.
## IMPRESSION:
1. Acute to early subacute infarction involving the left PCA distribution,
without hemorrhage.
2. Right middle cranial fossa arachnoid cyst extending along the right
convexity.
3. Mild paranasal sinus disease.
## NOTIFICATION:
The findings were discussed with , M.D. by
, M.D. on the telephone on at 4:54 pm, 2
minutes after discovery of the findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19096902", "visit_id": "20279889", "time": "2151-09-22 15:24:00"} |
14494129-DS-15 | 741 | ## HISTORY OF PRESENT ILLNESS:
male with past medical history significant for coronary
artery disease, hypertension, and recent upper respiratory
infection was admitted from the ED with rash.
He reports 7 days of fever, malaise, fatigue, rhinorrhea, dry
cough, which have now resolved. He took a course of an
antibiotic (unsure of the name) and ibuprofen with improvement
in his symptoms. Then since , he developed an itchy rash
that started on his abdomen and then spread throughout his body.
He was evaluated at an urgent care appointment on at
which time he was diagnosed with a likely viral exanthem and was
prescribed benadryl and steroid cream. Since then, the rash has
spread and now involves his entire body. His review of systems
is notable for the following:
- similar rash approximately years ago while in the
- recent exposures include pesticide treatments at his home
- recent travel includes trips to and when
he was driving and walking around lakes, no tick bites that he
can remember
- no new detergents, clothes, or soaps that he can remember
- bilateral hand pain
Upon arrival in the ED, vital signs were temp 98.6, HR 105, BP
171/88, RR 18, and pulse ox 100% on room air. While in the ED,
he received ceftriaxone and doxycycyline. Dermatology evaluated
him in the Emergency Department and thought the etiology of his
symptoms was unclear but most consistent with a small vessel
vasculitis. They recommended starting him on steroids and
hydroxyzine.
Review of systems:
(+) Per HPI.
(-) Denies fever, chills, night sweats, weight loss, sinus
tenderness, shortness of breath, chest pain or tightness,
palpitations, nausea, vomiting, constipation, abdominal pain,
change in bladder habits, dysuria, arthralgias, or myalgias.
## PAST MEDICAL HISTORY:
1. Hypertension
2. Coronary artery disease
3. Hyperlipidemia
4. h/o Basal Cell Carcinoma on nose in
## FAMILY HISTORY:
Mother - died at - cancer, unsure of the type
Father - died at - heart disease
Brother - healthy
## GEN:
no acute distress, very pleasant, lying comfortably in bed
## HEENT:
Clear OP, MMM; hard palate with erythema but no erosions
or ulceration
## NECK:
Supple, No LAD, No JVD
## CV:
RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
## LUNGS:
CTA, BS , No W/R/C
## ABD:
Soft, NT, ND. NL BS. No HSM
## EXT:
No edema. 2+ DP pulses
## NEURO:
A&Ox3. Appropriate. CN grossly intact. Preserved
sensation throughout. strength throughout. Normal
coordination. Gait assessment deferred
## PSYCH:
Listens and responds to questions appropriately, pleasant
## SKIN:
erythematous and blanching maculopapular rash throughout
body but sparing the face; legs with erythematous, blanching
maculopapular rash that is becoming confluent throughout the
lower extremities
## MICROBIOLOGY:
Blood Cx x 2 pending
## STUDIES:
- CXR - final read pending
## BRIEF HOSPITAL COURSE:
ASSESSMENT / PLAN:
male with past medical history of hypertension and coronary
artery disease was admitted from the ED with rash.
.
1. Rash
Etiology of his symptoms appears unclear. Differential diagnosis
include most likely drug rash in response to medications or
vasculitis. Hypersensitivity response is likely in the setting
of eosinophilia. New onset of vasculitis in this patient appears
unlikely, although is possible. Infection is also in the
differential, including spotted fever or Lyme
disease. Additional possibility includes viral exanthem,
although this response is more involved and progressive compared
to usual exanthem. Plan is the following: empiric rx. for RMSF
for one week. Two week steroid taper. Outpatient follow up
with dermatology and PCP as described below.
## MEDICATIONS ON ADMISSION:
1. Plavix 75mg PO q MWF
2. Toprol XL 50mg PO daily
3. Pravastatin 20mg PO qhs
## HOME MEDICATIONS CONTINUED:
1. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 1 weeks.
Disp:*14 Capsule(s)* Refills:*0*
2. Prednisone 10 mg Tablet Sig: as per taper, below Tablet PO
once a day for 14 days: 6 tab/day: 2days
4 tab/day: 4 days
2 tab/day: 4 days
1 tab/day: 4 days then stop .
Disp:*40 Tablet(s)* Refills:*0*
## DISCHARGE DIAGNOSIS:
Likely hypersensitivity syndrome with rash vs. small vessel
vasculitis vs. (less likely) spotted fever.
## DISCHARGE INSTRUCTIONS:
Resume your home medications. I have prescribed only:
antibiotics and steroids - take as prescribed.
You will need to follow up with dermatology tomorrow - they will
call you with appointment; they will relay the biopsy results to
you. You should also follow up with Dr. - call for
appointment.
Return to the Emergency Room for: fevers, malaise,
worsening rash.
You are being treated emperically for spotted
fever with antibiotics. Take these as prescribed below.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "14494129", "visit_id": "29981559", "time": "2111-06-17 00:00:00"} |
12989304-RR-56 | 249 | ## INDICATION:
year old man with hx of rt lung ca/pleural involvement/on
chemo // compare to
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 6.6 s, 43.0 cm; CTDIvol = 7.0 mGy (Body) DLP = 297.3
mGy-cm.
Total DLP (Body) = 297 mGy-cm.
## FINDINGS:
Thyroid is unremarkable. Prominent mediastinal lymph nodes are stable and not
pathologically enlarged. For example, the largest preesophageal lymph node
(03:24) measures 8 mm in short axis. Punctate calcification at the
paraesophageal location (03:48) is unchanged. Thoracic aorta and main
pulmonary artery are normal size. Heart is mildly enlarged. There is no
large central pulmonary embolism. There is no pericardial effusion.
Airways are patent to subsegmental levels. There is no pleural effusion.
Centrilobular emphysema is moderate.
Right pleural metastatic seeding with particular involvement of the fissures
appear similar to before. The nodularity at the left posterior pleural
surface (5:257) appears slightly increased compared to , the most
prominent nodularity currently measuring 8 x 3 mm previously measured 8 x 1
mm. There has been interval resolution of opacities in the left
lower lobe.
Limited evaluation of upper abdomen is notable for a 5.0 x 3.3 cm right renal
cyst which is stable. The small sclerotic lesions in the posterior right
eighth rib, lateral seventh rib and right lateral fourth rib are unchanged.
## IMPRESSION:
1. Stable metastatic pleural disease on the right.
2. Left pleural nodularity is slightly larger than before and may reflect
subpleural atelectasis.
3. Moderate emphysema.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12989304", "visit_id": "N/A", "time": "2124-07-27 08:32:00"} |
12833675-RR-75 | 542 | ## INDICATION:
year old woman s/p L4-5 laminectomy in , with recurrent
lower back pain radiating to the left hip/ buttock, despite conservative
measures// r/o new disc herniation vs. facet arthropathy vs. scarring
## FINDINGS:
Study is moderately degraded by motion, especially on postcontrast imaging.
Within these confines:
For the purposes of numbering, the lowest rib bearing vertebral body was
designated the T12 level.
Minimal L4 on L5 anterolisthesis is again noted question slightly progressed
compared to prior exam, measuring up to 2 mm (see 03:12 on current study
and 02:11 on prior exam). Transitional anatomy with partial sacralization of
L5 is again noted. Vertebral body heights are preserved. L4-5 mixed probable
type 1 and changes are noted without definite evidence of epidural
collection. Schmorl's nodes are seen at the L3 inferior endplate and L5
superior endplate.
Postsurgical changes related to interval left L4-L5 laminotomy are noted.
The visualized portion of the spinal cord is grossly preserved in signal and
caliber.
There is diffusely reduced T2 signal within the intervertebral discs, likely
on a degenerative basis.
There is no paravertebral or paraspinal mass identified and there is no
evidence of infection or neoplasm.
At T12-L1 there is disc bulge, mildvertebral canal and no neural foraminal
narrowing.
At L1-2 there is symmetric disc bulging and facet osteophytes mild vertebral
canal narrowing and mild bilateral neural foraminal narrowing. Unchanged from
prior.
At L2-3 there is symmetric disc bulging, a small new left central disc
protrusion and facet osteophytes with mild vertebral canal narrowing and mild
bilateral neural foraminal narrowing.
At L3-4 there is symmetric disc bulging which contacts bilateral transiting L4
nerve roots and facet osteophytes with mild vertebral canal narrowing, mild
left and mild-to-moderate right neural foraminal narrowing. Unchanged from
prior.
At L4-5 there has been interval decrease in size of the left central disc
protrusion possibly relating to a prior partial microdiscectomy. Evidence of
subtle enhancement in the region of the left lateral recess likely represents
postsurgical scar tissue. Superimposed ligamentum flavum thickening and facet
osteophytes result in mild vertebral canal narrowing, mild-to-moderate right
and moderate left neural foraminal narrowing.
At L5-S1 there is mild symmetric disc bulging, ligamentum flavum thickening
and uncovertebral osteophytes without significant vertebral canal or neural
foraminal narrowing. Unchanged from prior.
## OTHER:
There are multiple bilateral renal cysts measuring up to 3.7 cm.
Redemonstrated are multiple perineural cysts identified at the S1 level,
likely representing Tarlov cysts. Findings suggestive of ascending colon
diverticulosis (see 7:1).
## IMPRESSION:
1. Study is moderately degraded by motion.
2. Postsurgical changes related to interval left L4-L5 laminotomy and likely
partial microdiscectomy with interval decrease in size of the previously
described left central disc protrusion, and evidence of postoperative scar
tissue within the L4-L5 left lateral recess.
3. New small left central disc protrusion at L2-L3.
4. Question minimal interval progression of L4 on L5 anterolisthesis compared
to prior exam, still noted to be grade 1, measuring up to 2 mm.
5. Interval progression of multilevel degenerative changes of the lumbar spine
are most significant at L3-L4 where there is mild vertebral canal narrowing.
6. Findings suggestive of diverticulosis as described.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12833675", "visit_id": "N/A", "time": "2152-08-31 08:08:00"} |
16728529-RR-15 | 234 | ## EXAMINATION:
LIVER OR GALLBLADDER US (SINGLE ORGAN)
## INDICATION:
with new onset elevated LFTs, abdominal distension // eval
for cirrhosis, ascites
## LIVER:
Hepatic parenchyma is diffusely echogenic. The contour of the liver is
smooth. A well-circumscribed relatively hypoechoic lesion in the right
hepatic lobe in segment IV measures approximately 5.4 x 4.7 x 4.1 cm, and
demonstrates posterior acoustic enhancement. There is no demonstrable
internal vascularity. The main portal vein is patent with hepatopetal flow.
There is no ascites. An ill-defined area of relative hypo echogenicity is
noted in the gallbladder fossa, likely focal fatty sparing.
## BILE DUCTS:
There is no intrahepatic biliary dilation. The CBD measures 6 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 9.2 cm.
## RETROPERITONEUM:
Visualized portions of aorta and IVC are within normal
limits.
## IMPRESSION:
1. Echogenic liver consistent with steatosis. Other forms of liver disease
including hepatic fibrosis or cirrhosis or steatohepatitis cannot be excluded
on the basis of this examination.
2. 5.4 cm rounded hypoechoic lesion in hepatic segment IV has no internal
vascularity, potentially a complex hepatic cyst. Dedicated MRI of with
contrast could be obtained on a non urgent basis for further assessment.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16728529", "visit_id": "26498894", "time": "2165-05-10 20:27:00"} |
16446532-RR-77 | 203 | ## EXAMINATION:
CT HEAD W/O CONTRAST Q111 CT HEAD
## INDICATION:
year old man with fall with hx of head bleed with worsening
mental status// ?intracranial bleed
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 8.0 s, 16.6 cm; CTDIvol = 56.3 mGy (Head) DLP =
936.5 mGy-cm.
2) Sequenced Acquisition 3.0 s, 6.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
301.0 mGy-cm.
Total DLP (Head) = 1,238 mGy-cm.
## FINDINGS:
Exam is again mildly limited by patient motion, despite repeat scanning.
Within these limits, there is no evidence of acute large territorial
infarction, large hemorrhage. There is prominence of the ventricles and sulci
suggestive of involutional changes. Encephalomalacia in the right posterior
temporal lobe is again noted. Periventricular and subcortical white matter
hypodensities are presumed to be sequela of small-vessel ischemic disease.
There is no evidence of acute displaced fracture. The visualized portion of
the paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
Patient is status post bilateral lens replacements. Otherwise, the visualized
portion of the orbits are unremarkable.
## IMPRESSION:
Mildly limited exam due to patient motion, despite repeat scanning. Within
these limits, no evidence of large acute territorial infarct or hemorrhage.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16446532", "visit_id": "22850272", "time": "2182-06-02 21:45:00"} |
11102747-RR-36 | 62 | ## HISTORY:
male with multifocal hepatocellular carcinoma status
post chemoembolization. The patient has rising alpha-fetoprotein titers and
requires reassessment.
## BONE WINDOWS:
No suspicious lytic or sclerotic bone lesion.
## IMPRESSION:
Persistent residual enhancement of multiple liver lesions
following chemoembolization which have again slightly increased in size. No
new lesions seen.
The staff radiologist, Dr. has reviewed the images and the report.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11102747", "visit_id": "N/A", "time": "2174-01-13 12:56:00"} |
10157362-RR-72 | 95 | ## INDICATION:
year old man with history of right renal cell carcinoma status
post ablation in
## FINDINGS:
The right kidney measures 9.5 cm. The left kidney measures 10.0 cm.
Hypoechoic area is again demonstrated within the right upper renal pole,
consistent with post ablation scarring.
There is no hydronephrosis, stones, or masses bilaterally.
Normal cortical echogenicity and corticomedullary differentiation are seen
bilaterally.
The bladder is moderately well seen and normal in appearance.
## IMPRESSION:
Stable post-ablation scarring in the upper right kidney pole. No evidence of
soft tissue masses in bilateral kidneys.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10157362", "visit_id": "N/A", "time": "2183-07-11 09:56:00"} |
11341222-DS-8 | 1,007 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Left carotid endarterectomy and Dacron patch angioplasty
Carotid angioplasty and stenting
## HISTORY OF PRESENT ILLNESS:
This gentleman has been followed
for some time with asymptomatic carotid stenosis and also
intermittent claudication. His left carotid stenosis has
progressed from the 70-80-99% range without associated
symptoms.
## PAST MEDICAL HISTORY:
HTN, degenerative arthritis, hyperlipidemia
## SOCIAL HISTORY:
No ETOH, No tobacco (quit 64')
## GEN:
Alert and Oriented, patient comfortable, NAD
## HEENT:
atraumatic, normocephalic, EOMI, sclera non-icteric, Left
Carotid Bruit
## CV:
RRR, no murmurs, gallops, rubs S1S2+, no thrills/heaves
## RESP:
Symmetric respiratory excursion, CTAB, no
wheezes/crackles/rubs
## EXT:
no clubbing/cyanosis/edema, carotid pulses symmetric with
good upstroke
## BRIEF HOSPITAL COURSE:
Pt admitted for elective L Carotid endaretrectomy. While
in PACU patient had episode of hypotension, bradycardia;
atropine was administered, SBP120's, pt was noted to be aphasic
with motor deficit of RUE/RLE. An emergent duplex was performed
but technically difficult due to dacron patch. Heparin was
started and pt taken for stat CT angio which demonstrated a 1cm
filling defect at or distal to anastomosis. Returned to OR
emergently for exploration; dissection of the distal L ICA was
noted, re-patch angioplasty, angiogram w/stent placement were
performed. Post-operatively pt was admitted to the ICU. ,
were started, Nitroglycerin drip was used to control BP, IV
morphine for pain, insulin drip for tight blood sugar control.
No persistant neurologic deficits were noted. Pt transfered to
VICU on POD1, diet advanced, JP drain was d/c'd. Patient was
discharged on POD#2. At the time of discharge, the patient was
doing well, afebrile with stable vital signs. The patient was
tolerating a regular diet, ambulating, voiding without
assistance, and pain was well controlled. No persistent
neurologic deficits were noted. Instructions were given
regarding f/u, care of surgical site, and contact information
for any questions or concerns that should arise.
## MEDICATIONS ON ADMISSION:
Amlodipine-Benazepril [Lotrel] 10 mg-20 mg Capsule QD, Lipitor
80 mg QD, 75mg QD (stopped 81, Atenolol 25'
## 1. LOTREL MG CAPSULE SIG:
One (1) Capsule PO once a day.
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
## 6. PERCOCET MG TABLET SIG:
One (1) Tablet PO every
hours as needed for pain for 30 doses.
Disp:*30 Tablet(s)* Refills:*0*
## DISCHARGE DIAGNOSIS:
Asymptomatic left carotid artery stenosis
Left internal artery carotid dissection
## MEDICATIONS:
Take Aspirin 325mg (enteric coated) once daily
Take (Clopidogrel) 75mg once daily
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
1. Surgical Incision:
It is normal to have some swelling and feel a firm ridge along
the incision
Your incision may be slightly red and raised, it may feel
irritated from the staples
2. You may have a sore throat and/or mild hoarseness
Try warm tea, throat lozenges or cool/cold beverages
3. You may have a mild headache, especially on the side of your
surgery
Try ibuprofen, acetaminophen, or your discharge pain
medication
If headache worsens, is associated with visual changes or
lasts longer than 2 hours- call vascular surgeons office
4. It is normal to feel tired, this will last for weeks
You should get up out of bed every day and gradually increase
your activity each day
You may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
5. It is normal to have a decreased appetite, your appetite will
return with time
You will probably lose your taste for food and lose some
weight
Eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
No driving until post-op visit and you are no longer taking
pain medications
No excessive head turning, lifting, pushing or pulling
(greater than 5 lbs) until your post op visit
You may shower (no direct spray on incision, let the soapy
water run over incision, rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
Take all the medications you were taking before surgery,
unless otherwise directed
Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
You should not have an MRI scan within the first 4 weeks after
carotid stenting
Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
Changes in vision (loss of vision, blurring, double vision,
half vision)
Slurring of speech or difficulty finding correct words to use
Severe headache or worsening headache not controlled by pain
medication
A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
Trouble swallowing, breathing, or talking
Temperature greater than 101.5F for 24 hours
Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Numbness, coldness or pain in lower extremities
Bleeding from groin puncture site
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "11341222", "visit_id": "25932483", "time": "2127-06-02 00:00:00"} |
18432150-RR-19 | 99 | ## INDICATION:
Patient status post motor vehicle accident, now with worsening
headache and pain with lateral eye movements. Assess for intracranial
hemorrhage or subdural hematoma.
## FINDINGS:
There is no evidence of acute intracranial hemorrhage, mass effect, edema, or
pathologic extraaxial collection. The sulci and ventricles are normal in size
and configuration.
The paranasal sinuses and mastoid air cells appear well aerated. No fracture
is seen. The globes and other orbital soft tissues appear unremarkable on
noncontrast evaluation.
## IMPRESSION:
No evidence of an acute intracranial process. MRI would be more sensitive for
orbital or cavernous sinus pathology, if indicated.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18432150", "visit_id": "25925914", "time": "2143-06-08 11:32:00"} |
16114976-RR-135 | 289 | CT CHEST WITHOUT CONTRAST
## REASON FOR EXAM:
with neutropenic fever. Evaluate for acute
change.
## FINDINGS:
Since the prior study, new 4 mm peripheral nodular opacities are in
the left posterior costophrenic angle (4:194, 165). Minimal focal
peribronchial ground- glass opacity is also new in the left lower lobe.
Diffuse ground- glass opacities overall significantly decreased, with residual
very subtle centrilobular ground-glass nodules. There is no new focal area of
consolidation. Scattered mediastinal lymph nodes are unchanged. Small
pericardial effusion increased, and trace bilateral pleural effusions are
unchanged. Signs of anemia are suggested by relative hypodensity of
intracardiac blood. Minimal dependent atelectasis is present. Coronary
artery calcifications and mitral annulus calcifications are unchanged. The
main pulmonary artery is 3 cm wide, unchanged since the prior study. Airways
are patent to the subsegmental levels.
This study was not tailored for subdiaphragmatic evaluation except to note
prior splenectomy and distal pancreatectomy. Hepatic lesions are not well
depicted, should be evaluated by dedicated abdominal imaging.
There is no bone lesion suspicious for malignancy. Sclerotic foci in T3 and
L1 are unchanged since , may be denser than . Right rib fracture is
now healed.
## IMPRESSION:
1. New 4 mm peripheral opacities in the left costophrenic angle and new
subtle focal peribronchial ground-glass opacity in the left lower lobe,
probably too small to be clinically relevant but should be nevertheless
followed depending on symptoms, not later than in 8 weeks.
2. Small pericardial effusion and trace bilateral pleural effusion.
3. Signs of anemia.
4. Questionable signs of pulmonary hypertension.
5. Incompletely evaluated hepatic lesions, should be correlated with recent
MRI.
6. Overall significant decrease in diffuse ground-glass opacity, with
very subtle residual centrilobular ground-glass nodules, probably of no
clinical significance.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16114976", "visit_id": "21556197", "time": "2118-07-23 14:43:00"} |
11188695-RR-57 | 285 | ## HISTORY:
woman with a long history of multiple hernias, now with
likely recurrence, question recurrent right-sided hernia.
## FINDINGS:
Mild atelectasis is seen in the lung bases, particularly the left
upper lobe and left lower lobe. No evidence of pleural or pericardial
effusion. Patient is status post bilateral breast implants.
## CT ABDOMEN WITH IV CONTRAST:
Liver is unremarkable. Patient is status post cholecystectomy. Mild
intrahepatic biliary dilation is again seen, and it is stable when compared to
prior CT scans dating back to . Pancreas, spleen, adrenal
glands, and right kidney appear normal. There is a stable hypoattenuating
lesion in the left kidney which measures 2.8 cm and most likely represents a
renal cyst.
Atherosclerotic disease is noted in the abdominal aorta, which is normal in
course and caliber. Patient is status post gastric bypass surgery. Small and
large bowel are otherwise unremarkable. No evidence of bowel wall thickening
or obstruction. Opacified ureters are normal in course and caliber.
No evidence of free fluid or free air in the abdomen or pelvis. There are
scattered subcentimeter mesenteric and retroperitoneal lymph nodes.
Mild abdominal diastasis of the rectus abdominis muscles is again noted. No
evidence of abdominal wall hernia. There are small fat-containing bilateral
inguinal hernias.
## CT PELVIS WITH IV CONTRAST:
Bladder is distended and appears normal. The
uterus is unremarkable. No evidence of pelvic or inguinal lymphadenopathy.
## OSSEOUS STRUCTURES:
Multilevel degenerative changes are seen in the lower
thoracic and lumbar spine. No suspicious osteolytic or osteoblastic lesions.
## IMPRESSION:
1. No evidence of an abdominal wall hernia. There is persistent diastasis of
the rectus abdominis muscles. Note is made of small bilateral fat-containing
inguinal hernias.
2. Stable mild intrahepatic bile duct dilation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11188695", "visit_id": "N/A", "time": "2140-09-25 08:03:00"} |
12476201-RR-18 | 317 | ## INDICATION:
year old man POD 3 status post aortic and tricuspid valve
replacement for endocarditis, now with left-sided weakness. Evaluate for
abscess or infarction.
## FINDINGS:
Study is moderately degraded by motion, especially on postcontrast imaging.
Within these confines:
There are multifocal areas of gyriform slowed diffusion involving the right
frontal and parietal vertex, posteromedial parietal lobe, and right occipital
lobe. Findings are confined to the cortex, without evidence of white matter
involvement. There is suggestion of increased diffusion signal in the left
frontal cortex ( ), with minimal correlate on ADC map, and may be
artifactual. The majority these areas demonstrate associated T2 FLAIR
hyperintensity. Findings are new from the prior MRI performed on .
Additionally, there are multiple new foci of predominantly right-sided GRE
susceptibility involving the right frontal vertex, right temporal lobe, right
splenium of the corpus callosum and right parietal lobe, suggestive of
microhemorrhages. Additional foci of blooming are noted in the right dorsal
midbrain (10:10), left frontal lobe (10:15), and posterior interhemispheric
fissure (10:14).
No evidence of abnormal enhancement after contrast administration. There is
no evidence of mass, mass effect, or midline shift. Ventricles and sulci are
normal in size and configuration. Dural venous sinuses are patent on MPRAGE.
The orbits are preserved. There is mild mucosal thickening of the ethmoid air
cells bilaterally.
## IMPRESSION:
1. Study is moderately degraded by motion.
2. Acute to subacute cortical infarctions involving the right frontal,
parietal, and occipital lobes, associated with scattered microhemorrhages,
concerning for embolic etiology, with differential consideration of vasculitis
and border zone hypotensive cerebral infarcts.
3. Additional left frontal cortical infarction versus artifact.
4. Additional new brainstem and left hemisphere punctate microhemorrhages.
5. Within limits of study, no definite evidence of cerebral abscess.
## NOTIFICATION:
The findings were discussed with , M.D. by
, M.D. on the telephone on at 5:30 pm, 10 minutes after
discovery of the findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12476201", "visit_id": "22836926", "time": "2113-05-13 13:19:00"} |
10367793-RR-92 | 104 | ## EXAMINATION:
KNEE (AP, LAT AND OBLIQUE) LEFT
## INDICATION:
year old man with left knee pain// assess alignment
## IMPRESSION:
There is plate and screw fixation of the comminuted tibial fracture, and there
is no change in alignment from prior. No periprosthetic complications when
compared to prior radiographs from . There is mild improvement of
the proximal tibial and fibular fractures. There is no new fracture or
dislocation seen. There are severe tricompartmental degenerative changes of
the knee. There is generalized demineralization. Heterotopic bone formation
is noted about the knee joint likely secondary to prior trauma since surgery.
There is a small knee joint effusion.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10367793", "visit_id": "N/A", "time": "2200-09-07 10:32:00"} |
18156104-DS-7 | 945 | ## MAJOR SURGICAL OR INVASIVE PROCEDURE:
- total thyroidectomy with Dr.
of Present Illness:
Ms. is a year old female with history of
multinodular
goiter, hypothyroidism 's thyroiditis, vitiligo,
and
type 1 diabetes. She was initially diagnosed with Hashimotos in
in and is currently followed by Dr. . She
takes levothyroxine, 6.5 tablets of 137 mcg tablets weekly and
has been clinically euthyroid by exam. She was referred to us
for
surgical management for her development of compressive symptoms
in the past 3 months including shortness of breath when looking
down or up and when laying flat in bed. Some dysphagia to solids
and occasional cough.
Weight gain of 40 pounds since without change in diet.
Some constipation (once every 2 days). Endorses swelling in the
ankles. No hoarseness.
Otherwise she reports no other symptoms of hyper or
hypothyroidism. No cold intolerance, cold, dry skin, hair loss,
muscle pains. No heat intolerance, weight loss, tremors,
diarrhea.
## PAST MEDICAL HISTORY:
Type 1 Diabetes, vitiligo, retinopathy, 's
## FH:
Mother - hypothyroidism
Sister - hypothyroidism, type I diabetes
## GEN:
AOx3 WN, WD in NAD
## HEENT:
NCAT, EOMI, anicteric, surgical dressing in place, c/d/I,
no hematoma or swelling
## PULM:
unlabored breathing with symmetric chest rise, no
respiratory distress
## ABD:
soft, NT, ND, no mass, no hernia
## EXT:
WWP, no CCE, no tenderness, 2+ B/L
Fluid Balance (last updated @ 640)
Last 8 hours Total cumulative 268ml
## IN:
Total 918ml, PO Amt 30ml, IV Amt Infused 888ml
## OUT:
Total 650ml, Urine Amt 650ml
Last 24 hours Total cumulative 1417ml
## IN:
Total 3217ml, PO Amt 180ml, IV Amt Infused 3037ml
## OUT:
Total 1800ml, Urine Amt 1800ml
## BRIEF HOSPITAL COURSE:
Ms. presented to holding at on
for a total thyroidectomy with Dr. . She tolerated the
procedure well without complications (Please see operative note
for further details). After a brief and uneventful stay in the
PACU, the patient was transferred to the floor for further
post-operative management. Her parathyroid and calcium levels
were within normal limits in PACU without need for further
intervention. She was started on thyroid hormone replacement on
POD 1 as routine.
## NEURO:
Pain was well controlled on Tylenol
## CV:
The patient was tachycardic throughout the admission, she
reports that she has always had a high heart rate, is afebrile,
denies chest pain, shortness of breath, appropriate UOP.
## PULM:
The patient remained stable from a pulmonary standpoint;
oxygen saturation was routinely monitored. Had good pulmonary
toileting, as early ambulation and incentive spirometry were
encouraged throughout hospitalization.
## GI:
The patient was initially kept NPO after the procedure. The
patient was later advanced to and tolerated a regular diet at
time of discharge. Patient's intake and output were closely
monitored
## GU:
At time of discharge, the patient was voiding without
difficulty.
## ID:
The patient was closely monitored for signs and symptoms of
infection and fever.
## HEME:
Surgery not concerning for excessive blood loss, no
clinical signs of anemia.
On , the patient was discharged to home. At discharge,
she was tolerating a regular diet, passing flatus, voiding, and
ambulating independently. She will follow-up in the clinic in
weeks. Warning signs for hypocalcemia were communicated.
This information was communicated to the patient directly prior
to discharge.
## MEDICATIONS ON ADMISSION:
CYCLOSPORINE [RESTASIS] - Restasis 0.05 % eye drops in a
dropperette. - (Prescribed by Other Provider)
INSULIN LISPRO [HUMALOG U-100 INSULIN] - Dosage uncertain -
(Prescribed by Other Provider)
LEVOTHYROXINE - levothyroxine 137 mcg tablet. 1 (One) tablet(s)
by mouth daily Fastiong with water only 1 hour prior to
breakfast
METRONIDAZOLE [METROGEL] - Dosage uncertain - (Prescribed by
Other Provider)
MINOCYCLINE - Dosage uncertain - (Prescribed by Other Provider)
## DISCHARGE MEDICATIONS:
1. Acetaminophen 1000 mg PO Q8H
Do not take more than 4000mg acetaminophen in 24 hours
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*50 Tablet Refills:*0
2. Artificial Tears 1 DROP BOTH EYES BID
3. Insulin Pump SC (Self Administering Medication)Insulin
Lispro (Humalog)
Target glucose: 80-180
MD has ordered consult
Use of medical equipment: Insulin pump
Reason for use: medically necessary and justified as
cannot provide this type of equipment or suitable alternative
not appropriate.
Provider acknowledges patient competent
4. Levothyroxine Sodium 137 mcg PO DAILY
5. MetroNIDAZOLE Topical 1 % Gel 1 Appl TP DAILY
## DISCHARGE DIAGNOSIS:
multinodular goiter, hashimoto thyroiditis
## DISCHARGE CONDITION:
stable, alert and oriented x3, ambulating without assistance
## DISCHARGE INSTRUCTIONS:
You were admitted to the inpatient general surgery unit after
your total thyroidectomy. 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 hormone
replacement, please take as prescribed. Monitor for symptoms of
low Calcium such as numbness or tingling around mouth/fingertips
or muscle cramps in your legs. If you experience any of these
symptoms please call Dr. for advice or if you
have severe symptoms go to the emergency room.
Please resume all regular home medications, unless specifically
advised not to take a particular medication and take any new
medications as prescribed. 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": "18156104", "visit_id": "27905790", "time": "2148-03-02 00:00:00"} |
15435175-RR-36 | 322 | ## EXAMINATION:
MR HEAD W AND W/O CONTRAST
## INDICATION:
year old woman with pontine hemorrhage. Etiology unclear.
Follow up scan for possible ?underlying lesion.
## FINDINGS:
Edema and extent of signal abnormality in the dorsal pons and left midbrain
has resolved. There is residual lesion in the left dorsal does demonstrating
central isointense signal with a rim of low signal on T1 weighted images,
central high signal with a rim of low signal on T2 weighted images,
susceptibility artifact on gradient echo images, and central contrast
enhancement on postcontrast images. This measures 1.5 cm craniocaudad on
image 10:117, and 0.6 cm transverse by 0.3 cm AP on image 2:9. There is no
surrounding edema.
There are no additional sites of blood products in the brain parenchyma.
There is no hydrocephalus or effacement of basal cisterns. Mild
periventricular T2 hyperintensity is nonspecific but likely secondary to mild
chronic small vessel ischemic changes in this age group. No acute infarction.
Major arterial flow voids appear grossly preserved. Dural venous sinuses
appear patent on postcontrast MP RAGE images.
There is near complete opacification of left mastoid air cells, new compared
to . There is also mild mucosal thickening in the ethmoid air
cells and left maxillary sinus.
## IMPRESSION:
1. 1.5 x 0.6 x 0.3 cm lesion with central contrast enhancement and rim of
hypointensity is now seen in the left dorsal pons, at the site of the prior
hematoma. Resolution of edema and mass effect. Diagnostic considerations
include a cavernous malformation. Malignancy is unlikely in the absence of
edema. However, follow-up is recommended.
2. New near-complete opacification of left mastoid air cells compared to
. Please correlate with symptoms.
## RECOMMENDATION(S):
Follow-up MRI in 3 months.
## NOTIFICATION:
The impression and recommendation above were entered by Dr.
on at 16:59 into the Department of Radiology critical
communications system for direct communication to the referring provider.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15435175", "visit_id": "N/A", "time": "2165-10-31 12:46:00"} |
15291664-DS-4 | 988 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
This is a year old right handed woman with a history of
hypothyroidism, possible TGA episode and prior syncopal episode
who presents with loss of consciousness with shaking this
afternoon.
The patient reports eating and drinking very little during the
day (had no breakfast or lunch). She went to a friends house and
was sitting in her kitchen around 4pm when she suddenly started
speaking "gibberish" (incomprehensible sounds), then jerked head
left, then right then dropped off her chair to the ground,
striking her forehead. She had seconds of whole body
shaking without incontinence then slowly regained consciousness
after about 5 minutes. She remained somewhat confused for about
minutes. She was transported to by EMS. She does recall
being in the ambulance. She does not recall being lightheaded
prior to the episode. She currently has a mild frontal headache
but otherwise is back to baseline.
The patient had a similar episode of loss of consciousness in
or last year where she was found down in her house after
her husband heard a thump. She hit her head on that occasion and
developed a post concussive syndrome.
The patient reports 2 nights ago vomiting several times. She
attributes this to taking an NSAID for some left knee pain. She
has had increased stress in the past week.
On neuro ROS, the pt denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, vertigo, tinnitus or hearing
difficulty. Denies current difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies rash.
## PAST MEDICAL HISTORY:
- Hypothyroidism
- Depression
- Glaucoma s/p iridectomy
- s/p cataract surgeries
- osteoarthritis
- s/p hysterectomy
- possible TGA vs confusional migraine
- Syncope with post concussive syndrome
- Congnitive testing "significant problems were noted in
aspects of cognition dependent on attention, multi-tasking and
speed of processing." thought due to microvascular changes
and/or
recent concussion.
## FAMILY HISTORY:
Father had . No known blood clotting
disorders. No early strokes or heart attacks. No family hx of
migraines or seizures.
## GENERAL:
Appears younger than age
## HEENT:
Small area of erythema at bridge of nose, no scleral
icterus noted, MMM, small area of abrasion on the tip of tongue
## SKIN:
no rashes or lesions noted.
## -MENTAL STATUS:
Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt. was able to name both high and low frequency objects. Speech
was not dysarthric. Able to follow both midline and appendicular
commands. There was no evidence of neglect.
-Cranial Nerves:
## II:
PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
## III, IV, VI:
EOMI without nystagmus. Normal saccades.
## V:
Facial sensation intact to light touch.
## VII:
No facial droop, facial musculature symmetric.
## VIII:
Hearing intact to finger-rub bilaterally.
## XI:
strength in trapezii and SCM bilaterally.
## XII:
Tongue protrudes in midline with normal strength
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA
L 5 5 5 5
R 5 5 5 5
-Sensory: No deficits to light touch, cold sensation,
proprioception throughout.
-DTRs:
Bi Tri Pat Ach
L 2 1
R 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. absent.
## # NEURO:
Mrs. was admitted for work up of this
episode concerning for seizure. She had a MRI that was stable
when compared to her previous one a few years ago. There was
evidence of diffuse microvascular disease that was unchanged
from her previous scan. She had a routine EEG that was normal.
She was seen by Dr. the epilepsy team who discussed
the risks/benefits of starting an AED. After discussion with her
husband, the pt deferred on starting an AED at this time. She
agreed to get a 48hr ambulatory EEG as an outpatient and follow
up in neurology as an outpatient. She had a normal neurological
exam and remained stable throughout the course of her hospital
stay. On she was deemed stable for discharge.
## #ID:
She had elevated nitrates and leukocytes in her UA. Her
urine culture grew E coli. She completed a 3 day course of
bactrim while hospitalized.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 125 mcg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Estrogens Conjugated 0.3 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Aspirin 81 mg PO DAILY
2. Estrogens Conjugated 0.3 mg PO DAILY
3. Levothyroxine Sodium 125 mcg PO DAILY
## DISCHARGE INSTRUCTIONS:
Dear were hospitalized due to symptoms of loss of consciousness
resulting from a SEIZURE. were admitted to work up the
etiology behind the episode. had a MRI that was stable when
compared to previous imaging. had an EEG that was normal. On
continued with a normal neurological exam and had no
further seizures. were deemed stable for discharge with
neurology follow up. were seen by the epilepsy fellow and
should follow up in the neurology epilepsy clinic as an
outpatient only if are able to get the outpatient 48hr
ambulatory EEG. If not, can follow up with Dr. in the
neurology department. The number has been provide dbelow. We
recommended starting an anti-seizure medication but after
discussion with your husband, decided that would not
start one at this time.
No changes were made to your medications.
There were no changes made to your medications.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15291664", "visit_id": "20260285", "time": "2173-02-04 00:00:00"} |
19234519-RR-13 | 154 | ## EXAMINATION:
MRI OF THE LUMBAR SPINE
## INDICATION:
Ms. is a female with hx of knee arthritis who
presented today for followup of recent traumatic injury with worsened
weakness/numbness of RLE, worsened LBP // ?disc injury ?e/o compression
?acute pathology
## FINDINGS:
From T11-12 through L4-5 levels, there is no evidence of significant disc
bulge or disc herniation seen. There is an incidental hemangioma in L3
vertebral body.
At L5-S1 level, disc bulging and degenerative change seen with a right-sided
disc herniation which extends inferiorly surrounding the right S1 nerve root.
There is mild surrounding enhancement due to epidural granulation.
The distal spinal cord and paraspinal soft tissues are unremarkable. There is
no intraspinal fluid collection. No abnormal intra or paraspinal enhancement
seen.
## IMPRESSION:
Right-sided L5-S1 disc herniation extending inferiorly to the right lateral
recess of S1 which could result in irritation of right S1 nerve root.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19234519", "visit_id": "N/A", "time": "2111-11-18 16:33:00"} |
14475964-RR-40 | 124 | ## HISTORY:
with right pneumothorax status post pigtail
placement on right // ?pigtail placement
## FINDINGS:
There is been interval placement of a right sided chest tube with pigtail
projecting over the right mid lateral hemithorax. A tiny residual
pneumothorax remains and there has been interval re-expansion of the right
lung. Small amount of fluid is seen within the minor fissure.
Cardiac and mediastinal contours are unchanged. The left lung remains grossly
clear. No focal consolidation is present. The pulmonary vasculature is not
engorged.
## IMPRESSION:
Interval placement of right-sided chest tube with marked interval decrease in
size of the right pneumothorax, with only a tiny residual pneumothorax
remaining. Interval re-expansion of the right lung. Small amount of fluid
within the minor fissure.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14475964", "visit_id": "N/A", "time": "2171-12-30 16:54:00"} |
17672648-RR-7 | 99 | ## HISTORY:
woman with large head laceration in the left parietal
region status post fall down multiple stairs, ETOH intoxication. On clinical
exam, the patient has no neurological deficit.
## FINDINGS:
There is no prevertebral soft tissue swelling. No disc, vertebral,
or paraspinal abnormality is seen. There is no sign of fracture or abnormal
alignment of the component vertebrae. Straightening of the cervical lordosis
is noted, likely due to cervical collar. CT is not able to provide
intrathecal detail comparable to MRI. The visualized outline of the thecal
sac appears unremarkable.
## IMPRESSION:
No evidence of acute fracture or spondylolisthesis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17672648", "visit_id": "N/A", "time": "2119-02-05 02:15:00"} |
17757767-DS-12 | 1,169 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## CHIEF COMPLAINT:
shortness of breath, rash
## HISTORY OF PRESENT ILLNESS:
The patient is a female with diabetes mellitus who presents
with shortness of breath.
.
The patient was in her usual state of health until last week
when she developed pruritis over her entire body. She denies
any new medications and presented to the ED for further
evaluation. While in the ED, she was evaluated with resolution
of her rash. She discharged with prednisone 60mg daily x 4 days
and benadryl. Since then, her rash persisted so she went to her
PCP's office and was given a script for certirizine. She
slightly improved but then developed dizziness associated with
dyspnea on exertion since this morning. She reports feeling her
throat closing so she presented to the ED for further
evaluation.
.
On arrival to the ED, vital signs were T- 98.0, HR- 100, BP-
132/64, RR- 16, SaO2- 100% on RA. D-dimer elevated to 5035 so
she underwent CTA which did not reveal PE (prelim read). While
in the ED, she was anxious and became tachycardic and
tachypneic, which was thought to be secondary to panic attacks.
Other labs pertinent for elevated WBC (currently on prednisone)
and normal troponin. EKG unchanged from prior. Of note, she
was never hypoxic. She is being admitted for workup of elevated
d-dimer and tachycardia/tachypnea.
.
On the floor, vital signs were T- 98.5, BP- 104/60, HR- 84, RR-
16, SaO2- 98% on RA. The patient felt better and denied any
shortness of breath, chest pain, dizziness, LH or syncope.
## PAST MEDICAL HISTORY:
1. Diabetes mellitus
2. GERD
3. s/p cholecystectomy
## FAMILY HISTORY:
No family history of early MI
Mother and sister with cervix CA
## GENERAL:
Alert, oriented, no acute distress
## HEENT:
Sclera anicteric, MMM, oropharynx clear
## NECK:
supple, JVP not elevated, no LAD
## LUNGS:
Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
## CV:
Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
## ABDOMEN:
soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
## EXT:
Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. no calf tenderness/swelling
## NEURO:
grossly intact, no focal deficits
## DERM:
no rash noted on face, arms, chest, abdomen.
## .
CTA CHEST :
No evidence of pulmonary emboli or other
acute process.
.
## ESOPHAGRAM :
1) Free gastroesophageal reflux into the distal esophagus.
2) Equivocal mucosal irregularity in the upper esophagus does
not obviously persist but raises the possibility of early
eosinophilic esophagitis.
3) Mild esophageal dysmotility.
## ASSESSMENT AND PLAN:
female with history of diabetes
mellitus presenting with shortness of breath and rash. She was
found to have urticaria, with unclear etiology, and discharged
on a steroid taper.
## #URTICARIA:
The patient developed an evanescent, recurring,
pruritic urticaria rash, with associated dermatographism. She
was started on prednisone, which will be tapered by 10 mg every
4 days after discharge. She was also given Benadryl,
fexofenadine, and famotidine. Allergy was consulted and will
follow up with the patient in clinic.
## #SHORTNESS OF BREATH:
The patient initially presented with
shortness of breath of unclear etiology. CTA was done due to
concern about elevated D-dimer and was negative for PE. By the
last few days in the hospital, the pulmonary symptoms had
completely resolved. The patient was given an epipen and
instructed to use it and come to the hospital if she developed
anaphylaxis.
## #DIABETES MELLITUS:
The patient's metformin was held on
admission, and the patient was managed on an insulin sliding
scale. Metformin was restarted on discharge.
## #?ESOSINOPHILIC ESOPHAGITIS:
The patient reported food sticking
in the esophagus. This was investigated with Barium esophagram,
showing a mucosal irregularity in the upper esophagus that does
not obviously persist but raises the possibility of eosinophilic
esophagitis and mild esophageal dysmotility. Allergy follow-up
was arranged.
## #TRANSITIONAL ISSUES:
TSH was mildly elevated during this
hospitalization. Will need to repeat as outpatient.
## DISCHARGE MEDICATIONS:
1. metformin 500 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO twice a day.
Disp:*60 Tablet Extended Rel 24 hr(s)* Refills:*0*
2. diphenhydramine HCl 25 mg Capsule Sig: Capsules PO Q6H
(every 6 hours) as needed for hives, itchiness.
Disp:*60 Capsule(s)* Refills:*0*
3. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritis.
Disp:*1 bottle* Refills:*2*
4. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
puffs Inhalation every hours as needed for shortness of
breath or wheezing.
Disp:*1 inhaler* Refills:*0*
5. prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day: Take 3 tablets daily for 4 days, then 2 tablets daily for 4
days, then 1 tablet daily for 4 days, then half tablet daily for
4 days, then stop.
Disp:*26 Tablet(s)* Refills:*0*
6. insulin lispro 100 unit/mL Insulin Pen Sig: as directed
Subcutaneous before meals: Use attached insulin sliding scale.
Disp:*1 pen* Refills:*2*
7. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*0*
8. Vitamin D3 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*2*
9. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*0*
10. One Touch Ultra System Kit Kit Sig: One (1) kit
Miscellaneous as directed: To monitor blood sugar.
Disp:*1 kit* Refills:*0*
11. One Touch Test Strip Sig: One (1) strip Miscellaneous
three times a day.
Disp:*100 each* Refills:*2*
## 12. LANCETS,ULTRA THIN MISC SIG:
One (1) Miscellaneous
three times a day.
Disp:*200 lancets* Refills:*2*
13. EpiPen 0.3 mg/0.3 mL Pen Injector Sig: One (1) pen
Intramuscular once as needed for anaphylaxis: Use only in case
of anaphylactic reaction.
Disp:*1 pen* Refills:*0*
## DISCHARGE DIAGNOSIS:
Primary- Urticaria
Secondary- Diabetes mellitus
## DISCHARGE INSTRUCTIONS:
You were admitted to the hospital with shortness of breath and a
rash. You were found to have urticaria, which is an allergic
condition. No clear precipitant was found. You were started on
steroids and antihistamines. You were seen by an allergy
specialist who will follow up with you as an outpatient.
The following changes were made to your medications:
1. START prednisone and taper as follows:
30 mg daily for 4 days, then
20 mg daily for 4 days, then
10 mg daily for 4 days, then
5 mg daily for 4 days, then stop.
2. INCREASE metformin to 500 mg twice daily
3. START benadryl every 8 hours as needed for itching
4. START fexofenadine (antihistamine)
5. START famotidine (antihistamine)
6. START sarna lotion (camphor-menthol) as needed for itching
7. START albuterol inhaler as needed for shortness of breath
We are giving you an Epipen, that should use if you are having
an anaphylactic reaction. If you use your epipen, you should go
to the emergency room.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17757767", "visit_id": "28818443", "time": "2131-02-05 00:00:00"} |
16614384-RR-30 | 96 | ## INDICATION:
year old man s/p CABG // eval for pneumo eval for pneumo
## IMPRESSION:
In comparison with the study of , the right chest tube remains in
place. It is very difficult to assess for pneumothorax, though there may be a
small residual on the right. This was discussed with the resident taking care
the patient. She is going tube put the chest tube on water seal, carefully
watching the patient to see if there is any adverse change in his condition.
If so, she will immediately get a repeat chest radiograph.
Otherwise, little change.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16614384", "visit_id": "20561844", "time": "2119-09-10 08:47:00"} |
17352692-RR-28 | 313 | ## EXAMINATION:
CTA HEAD AND NECK WITH PERFUSION PQ149 CT HEADNECK
## INDICATION:
Suspected stroke with acute neurological deficit.// Please
exclude ICH, signs of early ischemic stroke, large vessel occlusion, or other
vascular abnormality.
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Sequenced Acquisition 19.2 s, 8.0 cm; CTDIvol = 314.2 mGy (Head) DLP =
2,513.8 mGy-cm.
3) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 70.8 mGy (Head) DLP =
35.4 mGy-cm.
4) Spiral Acquisition 5.3 s, 42.0 cm; CTDIvol = 31.9 mGy (Head) DLP =
1,342.5 mGy-cm.
Total DLP (Head) = 4,795 mGy-cm.
## CT HEAD WITHOUT CONTRAST:
There is no evidence of infarction, hemorrhage, edema, or mass. The
ventricles and sulci are normal in size and configuration. Brain atrophy and
small vessel disease identified. Vague hypodensities extend in the basal
ganglia region. It is unclear whether this are due to small vessel disease.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
## CTA HEAD:
The vessels of the circle of and their principal intracranial branches
appear normal without stenosis, occlusion, or aneurysm formation. The dural
venous sinuses are patent.
## CTA NECK:
The carotid and vertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion. There is no evidence of internal carotid
stenosis by NASCET criteria.
## CT PERFUSION:
No abnormalities are identified.
## OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria.
## IMPRESSION:
1. No evidence of acute infarct, bleed or fracture.
2. No evidence of occlusion stenosis of the circle or major vessels of
the neck.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17352692", "visit_id": "22233391", "time": "2185-09-26 10:59:00"} |
14525215-RR-61 | 325 | ## INDICATION:
man with resected colon cancer and pancreatic cyst rule out
recurrence.
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 5.8 s, 76.2 cm; CTDIvol = 23.4 mGy (Body) DLP =
1,778.0 mGy-cm.
2) Spiral Acquisition 2.9 s, 37.7 cm; CTDIvol = 23.9 mGy (Body) DLP = 899.2
mGy-cm.
3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
4) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 33.5 mGy (Body) DLP =
16.8 mGy-cm.
Total DLP (Body) = 2,696 mGy-cm.
** Note: This radiation dose report was copied from CLIP (CT ABD AND
PELVIS WITH CONTRAST)
## THORACIC INLET:
The thyroid is unremarkable. Patient has a tracheostomy in
place. There are no enlarged supraclavicular lymph nodes.
## BREAST AND AXILLA:
There are no enlarged axillary lymph nodes.
## MEDIASTINUM:
There are no enlarged mediastinal hilar lymph nodes. Patient
status post sternotomy with the sternal wires remain broken with evidence of
nonunion of the sternal fragments. No evidence of osteomyelitis of fluid
collections around sternum. Heart size is normal. There is no pericardial
effusion. There is mild coronary artery calcification. The aorta and
pulmonary arteries are normal in caliber.
## PLEURA:
There is no pleural effusion
## LUNG:
Evaluation of lung parenchyma is limited by respiratory motion. There
is a stable 5 mm right lower lobe pulmonary nodule (302, 141). No new
pulmonary nodules.
## BONES AND CHEST WALL:
Review of bones shows evidence of median sternotomy.
Sternal sutures are intact.
## UPPER ABDOMEN:
Limited sections through the upper abdomen shows evidence of
cholecystectomy. No adrenal masses are seen. There is a cystic lesion in the
tail of pancreas. Please refer to dedicated report on abdomen which has been
dictated separately.
## IMPRESSION:
Stable 5 mm right lower lobe pulmonary nodule. No new pulmonary nodules.
Cystic lesion in the tail of pancreas. Please refer to dedicated report on
abdomen which has been dictated separately.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14525215", "visit_id": "N/A", "time": "2138-08-15 14:12:00"} |
13589710-RR-37 | 132 | ## FINDINGS:
The internal auditory canals are normal bilaterally. There is no
enhancing mass present or expansion of the IAC. The cerebellopontine cisterns
are patent bilaterally. The imaged portions of the VI, VII and VIII cranial
nerves are normal. The semicircular canals and cochlea are normal
bilaterally. The vascular structures are unremarkable.
There are no abnormalities in diffusion to indicate an acute infarction.
Ventricles are normal in size and configuration. Scattered areas of punctate
FLAIR hyperintensities are nonspecific but are thought to reflect sequela of
chronic small vessel ischemic disease. The flow voids of the principal
intracranial vascular structures are preserved. The bone marrow is normal in
signal. The included paranasal sinuses and mastoid air cells are well
aerated. The lenses and globes are normal.
## IMPRESSION:
No findings to explain tinnitus.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13589710", "visit_id": "N/A", "time": "2120-11-03 17:54:00"} |
14028461-DS-6 | 1,253 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
ERCP/EUS with necrosectomy and cyst drainage
## HISTORY OF PRESENT ILLNESS:
with hx of nonocclusive CAD, pAF on ASA, DM2, ?cirrhosis,
htn, HLD, complicated course following recent acute necrotizing
pancreatitis with infected pancreatic pseudocyst requiring
endoscopic drainage and prolonged antiobiotic treatment for E.
coli bacteremia now presenting with recurrent fevers after
completion of ertapenem IV on .
On the evening prior to presentation, he felt flushing in his
face. Wife checked aural temp, which was 101.1. He had been
counseled to come to ED if febrile by Dr. . The following
morning (day of PTA), he again felt flushed, had recurrent temp
to 101. He spoke to ID fellow, Dr - advised that he present
to ED for further evaluation. He reports that his abdomen feels
"sorer than normal because it hasn't had any food since noon" on
day of presentation, "like an ache." Currently . Abdominal
discomfort is epigastric and RUQ, nonradiating. Denies N/V,
diarrhea, constipation. Normal BM is soft, brown. Denies melena,
hematochezia. Endorses intermittent headaches, which he
attributes to dehydration, currently . Has not noted any
sinus pain. Denies edema. No recent travel. He has been
working on trying to build up his endurance after critical
illness; these days he is able to walk 500 feet down driveway to
get newspaper, do some weed whacking, but then needs to rest.
Denies dysuria, hematuria. Denies rash.
In the ED:
14:50 2 98.3 125 98% RA
Today 21:56 99.4 118 143/86 16 98% RA
+epigastric TTP, no rebound
site without erythema
Labs notable for:
LA 1.5
BUN/Cr
WBC 9.4
Hb 11.3
CT abd/pelvis with contrast with mildly decreased, walled-off
necrotic collection replacing much of pancreas. No other new
findings.
BCx x2 drawn
## ORDERED:
Zosyn 4.5 gm IV x1
2L NS
ERCP consulted, plan for admission for further evaluation
## PAST MEDICAL HISTORY:
-Acute necrotizing pancreatitis - hospitalized at
, for suspected gallstone pancreatitis, course c/b
demand NSTEMI, acute metabolic encephalopathy, new diabetes
requiring intiiation of insulin, severe acute protein calorie
malnutrition requiring placement. Rehospitalized
for E. coli bacteremia in the setting of infected
pancreatic pseudocyst, s/p endoscopic drainage of 2L
infected-appearing fluid and placement of 4 plastic stents.
Received antibiotics (Zosyn->ertapenem),
transitioned to ciprofloxacin 500 mg PO BID on for
continued drainage of pancreatic abscess.
-HTN
-HLD
-paroxysmal afib
-subdural hematoma while on ASA and Plavix,
-CAD - per cardiology note in OMR: "CAD s/p MI :
mLAD 40%, mRCA30%)"
-DM2
-?Cirrhosis
-L knee injury and repair (child)
-R knee replacement
-R Achilles tendon repair - , ruptured in the setting of
trying push his car when it ran out of fuel
-Right rotator cuff repair
## FAMILY HISTORY:
Father with coronary artery disease s/p 4v CABG and 100%
occluded L CEA with recurrent CVAs
Mother lived to , diagnosed with colon ca at , s/p colonic
surgery.
## GEN:
Delightful male, lying in bed, easily mobilizes, in NAD
## HEENT:
PERRL, EOMI, clear oropharynx, no cervical or
supraclavicular adenopathy, +facial flushing
## CV:
tachycardic, regular, no m/r/g
## LUNGS:
CTAB, no wheeze or rhonchi
## ABD:
soft, nondistended with palpable epigastric mass, mild TTP
at epigastrium and RUQ, no rebound or guarding, +BS
## EXT:
WWP, no clubbing, cyanosis or edema. 1+ DP on R, decreased
but palpable L DP. No asymmetry.
## NEURO:
A+O x3, spontaneously moving all extremities
## HEENT:
PERRL, EOMI, conjunctiva clear, anicteric, MMM
## CV:
RRR, Nl S1/S2, no MRG
## NEURO:
aao x3, CNs and strength grossly intact
## PSYCH:
appropriate, normal affect, not depressed
## EKG:
Sinus tachycardia at 102, LAD, QTc 399, TWI in III,
flattening in aVF, no ST segment changes, no Q waves, compared
to TWI in III are new (previously flat)
CT abd/pelvis with contrast:MPRESSION:
Persistent substantial moderate-sized, but mild decreased,
wall-off necrotic collection would replacing much of the
pancreas with cystgastrostomy tubes in place. Gas in
collection, as before, but not specific, particularly with
catheters in place. Unchanged biliary dilatation. Splenic vein
at least compressed and narrowed, but potentially occluded,
although not a new finding.
## BRIEF HOSPITAL COURSE:
y.o male with h.o CAD, pAF on ASA, DM2, ?cirrhosis, HTN, HL
with recent acute necrotizing pancreatitis with infected
pancreatic pseudocyst and ecoli bacteremia s/p IV abx, on PO
cipro who presented with fever.
.
#abdominal pain in the setting of recent necrotizing
pancreatitis and infected pancreatic pseudocyst.
CT abdomen showed continued necrotic pancreatic collection that
has mildly decreased, with draining tubes in place. LFTs not
particularly revealing. Fever thought to be due to continued
collections. GI and ID were consulted. U/A unrevealing. Pt had
diarrhea after CT scan and c.diff was negative. BCx sent and
were NGTD. Pt was placed on IV zosyn empirically while awaiting
blood cultures. The GI team performed a pancreatic necrosectomy
with stent placement and pus extraction on . Cause of fever
thought to be source control. ID has recommended at least 2
weeks of IV ertapenem therapy with f/u in clinic in 2 weeks
to discuss the need to extend this course of therapy longer.
.
#tachycardia-felt to be related to fever and the above. Improved
with IVF. Considered need to evaluate for PE but felt that the
above causes were more likely and pt with low wells score.
.
#non-occlusive thrombus of main portal vein and SMV-previously
incidentally noted. Decision was made not to anticoagulate at
the time due to h.o SDH.
.
#DM2-no longer on home insulin, has resolved with improvement in
pancreatic function.
.
#?Cirrhosis-Raised during last hospitalization, no evidence of
decompensation. Per prior GI recs needs liver imaging q6months
and afp screening. Non urgent screening endoscopy. This was
discussed with patient who will coordinate f/u with his PCP.
.
#afib-continued asa
.
#h.o NSTEMI-continude asa, not on plavix, continue statin,
metoprolol, lisinopril
.
#GERD-PPI continued
## # MUSCLE ACHES:
likey due to recent illness and increase in
exercise just prior to discharge. No focal sxs, low concern for
new pathology.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO QPM
2. Atorvastatin 40 mg PO QPM
3. Omeprazole 40 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. Lorazepam 0.5 mg PO QHS:PRN insomnia
7. Ciprofloxacin HCl 500 mg PO Q12H
## DISCHARGE MEDICATIONS:
1. Aspirin 325 mg PO QPM
2. Atorvastatin 40 mg PO QPM
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. Lorazepam 0.5 mg PO QHS:PRN insomnia
6. Ondansetron 8 mg PO Q8H:PRN nausea
7. Ertapenem Sodium 1 g IV DAILY Duration: 13 Doses
RX *ertapenem [Invanz] 1 gram 1 gram daily Disp #*13 Vial
## REFILLS:
*0
8. Outpatient Lab Work
Please draw the following labs on and :
CBC with differential, BUN, Cr, AST, ALT, TB, ALK PHOS
FAX to attn CLINIC - AT
## DISCHARGE DIAGNOSIS:
fever in the setting of recent bactremia and infected pancreatic
pseudocyst
diarrhrea
## DISCHARGE INSTRUCTIONS:
You were admitted for evaluation of fever in the setting of a
recent infected pancreatic cyst and blood stream infection. You
were evaluated by the infectious disease and gastroenterology
teams. You were treated with antibiotics while awaiting lab
testing. You underwent a EUS with cyst drainage on . The ID
team has recommended at least 2 weeks of IV ertapenem with
discussion of continuing for a longer course. You will discuss
this at your upcoming infectious disease appointment.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "14028461", "visit_id": "28036419", "time": "2137-07-26 00:00:00"} |
11063824-RR-97 | 101 | ## HISTORY:
man with end-stage dementia and new hypoxia. Evaluate
for worsening effusion or atelectasis.
## FINDINGS:
Portable semi-upright radiograph of the chest demonstrates near complete
opacification of the left hemithorax which likely represents a combination of
pleural effusion and adjacent atelectasis. There is no major shift of the
mediastinum. Over the interval, there has been slight increase in the
right-sided pleural effusion, which is still small. A right IJ central venous
line is seen with the tip terminating in the distal SVC.
## IMPRESSION:
Near-complete opacification of the left hemithorax indicates
enlarging pleural effusion with adjacent atelectasis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11063824", "visit_id": "22239740", "time": "2204-09-23 17:14:00"} |
13970310-RR-15 | 215 | ## INDICATION:
man status post fall with right periorbital
ecchymosis, oral bleeding. Evaluate for bleed.
## CT HEAD WITHOUT CONTRAST:
There are three foci of small subarachnoid
hemorrhage identified. The first is located in a right superior posterior
frontal sulcus. The second one involves the right sylvian fissure and the
third is located near the hippocampus on the right. There is no evidence of
epidural or subdural hematoma. There is no associated mass effect and no
midline shift. No transitorial herniation is identified. There is
generalized prominence of sulci and ventricular system consistent with central
atrophy. There are atherosclerotic calcifications of the cavernous portions of
the internal carotid arteries and left vertebral artery.
There is a right periorbital hematoma. The contents of the globe are
unremarkable. No fractures are identified.
Bone windows also reveal smooth thinning consistent with resorption of the
parietal bones of the skull bilaterally, right greater than left. Given the
history of parathyroid adenoma, this could be related to primary
hyperparathyroidism. The appearance does not favor a malignancy. There is
mild mucosal thickening in the maxillary sinuses without air-fluid levels.
## IMPRESSION:
1. Multifocal subarachnoid hemorrhage.
2. Right periorbital hematoma.
3. Incidental finding of smooth thinning/resoprption of the parietal skull
bilaterally, which is likely related to the patient's primary
hyperparathyroidism.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13970310", "visit_id": "22485662", "time": "2155-01-01 14:41:00"} |
19902080-RR-43 | 214 | ## EXAMINATION:
CT HEAD W/O CONTRAST Q111 CT HEAD
## INDICATION:
year old woman with sroke and afib // clot? bleed? compare to
before
## DOSE:
This study involved 3 CT acquisition phases with dose indices as
follows:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 6.4 s, 17.0 cm; CTDIvol = 52.9 mGy (Head) DLP =
897.1 mGy-cm.
Total DLP (Head) = 897 mGy-cm.
## FINDINGS:
There is a small amount of residual subarachnoid hemorrhage noted within the
right parietal sulci, significantly decreased from the prior examination. No
new foci of intraparenchymal or extra-axial hemorrhage is identified.
Redemonstrated is a subacute left occipital infarction. Subtle, asymmetric
loss of gray-white matter differentiation involving the right cerebral
hemisphere, predominantly in the MCA/PCA territory, corresponds with the
patient's prior infarction. No new large vascular territory infarction is
present. The basal cisterns remain patent.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
## IMPRESSION:
1. Small, residual right parietal subarachnoid hemorrhage without evidence of
mass effect or midline shift.
2. Redemonstration of late subacute left occipital and right parietal
infarctions, without evidence for new, large vascular territorial infarction.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19902080", "visit_id": "22278279", "time": "2152-11-17 12:38:00"} |
11293159-RR-23 | 674 | ## MEDICAL HISTORY:
man with left eye proptosis, chemosis, pulsatile
tinnitus.
## REASON FOR EXAM:
Please evaluate for carotid cavernous fistula.
## TASKS PERFORMED:
Diagnostic cerebral angio with left vertebral arteriogram,
right internal carotid arteriogram, right external carotid arteriogram, left
internal carotid arteriogram, left external carotid arteriogram, left internal
maxillary artery arteriogram, left middle meningeal arteriogram.
## ANESTHESIA:
The patient was under moderate sedation provided by
administration of divided dose of 200 mcg fentanyl and 5 mg of Versed
throughout the total procedure time of 70 minutes, during which he was
hemodynamically stable and his parameters were continuously monitored.
## OPERATORS:
Dr. and Dr. .
## DETAILS OF THE PROCEDURE:
Informed consent was obtained from the patient
after explaining risks, benefits, indication and alternative management.
Patient was brought to the neurointerventional suite and placed in supine
position on the biplane fluoroscopic table. Preprocedural time-out was
performed documenting the nature of the procedure, the patient identity using
two independent verifiers. Both groins were prepped and draped in normal
sterile fashion. After injection of the local anesthetic into the right
femoral area, the right common femoral artery was accessed using micropuncture
set. With the Seldinger technique, a FR vascular sheath was successfully
placed into the right common femoral artery. Through the sheath, a FR
2 catheter was inserted with the aid of .038 angled glidewire. The
above-mentioned vessels was selectively catheterized and arteriogram were
performed from these locations. Then through the catheter, rapid
transit microcatheter with gold tipped microwire were inserted and selective
catheterization of the left internal maxillary arteriogram and the left middle
meningeal arteriogram were done. After acquisition of the appropriate
imaging, catheters and wires were withdrawn. The vascular sheath was removed
and pressure was applied to the right groin until hemostasis was obtained for
a total of 20 minutes. The procedure was uneventful and the patient tolerated
the procedure well without complication. The patient went to the floor with
post procedure order.
## FINDINGS:
Right vertebral artery arteriogram showed distal portion of right vertebral
artery appears unremarkable with reflux into distal right vertebral artery.
Both sides appear similar in size. , AICA, SCA and PCA's appear normal in
course and caliber.
Right internal carotid arteriogram showed normal cervical, petrous, cavernous
and supraclinoid portions of the ICA. Early filling of the cavernous sinus
was seen through meningeal branches of cavernous portion of the ICA indicative
of the presence of type B carotid cavernous fistula. Both MCA and ACA were
seen and appeared normal.
Right external carotid arteriogram showed normal vessel and its branches.
There was no dural AV fistula .
Left internal carotid arteriogram showed normal cervical, petrous, cavernous
and supraclinoid portions of the ICA. Both ACA and MCA were seen and appeared
normal with normal branches. There was communication between cavernous
portions of the left ICA and cavernous sinuses and early appearance of
engorged left superior orbital vein. Communication appears to be through
numerous small meningeal branches of the ICA in the cavernous segment. The
cavernous sinus drains anteriorly through superior ophthalmic vein. There is
no drainage into the facial vein. Posteriorly there is intracavernous
connection and seems to drain mostly to right sigmoid sinus through the the
right inferior petrosal and to lesser extent to left side.
Left external carotid arteriogram showed normal vessels and normal distal
branches. Both internal maxillary and superficial temporal were seen. There
was some filling of the cavernous sinus coming through the middle meningeal
branch of the internal maxillary artery . This was more obvious with
subsequent acquisition of arteriograms through internal maxillary and it's
middle meningeal branch which showed mild opacification of the left cavernous
sinus . This signifies the presence of type D cavernous sinus fistula on the
left side.
## IMPRESSION:
Cerebral angiogram demonstrates the presence of bilateral
carotico cavernous sinus fistulas. On the left side the communications appear
to be from branches of both ICA and ECA signifying type D cavernous sinus
fistula. On the right side, the patient seems to have possible type B
cavernous sinus fistula with communication between meningeal branches of
right ICA and the cavernous sinus.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11293159", "visit_id": "26642559", "time": "2178-01-24 09:23:00"} |
17176117-DS-5 | 979 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
with CAD s/p CABG in (Coronary artery bypass grafting
x3,
with left internal mammary artery graft to left anterior
descending, reverse saphenous vein graft to diagonal branch
of the posterior descending artery), NSTEMI , CVA
previously requiring G-tube for dysphagia, afib on Coumadin,
anemia of chronic disease who is transferred from for
further management of decompensated heart failure.
He was admitted to on after experiencing SOB for
several days. This was initially presumed prior to admission to
be pneumonia and he received levaquin. His SOB progressed such
that he couldn't ambulate, and so he presented to the ED. There
he was in aflutter and received diltiazem, as well as 60 mg IV
Lasix. Labs notable for from baseline 1.2 to 1.7, lactate
4.6, INR 7.2, neg trop. He was in heart failure, and had
relative hypotension requiring CCU care and phenylephrine
pressure support. There was some concern for sepsis triggering
his heart failure and was on vancomycin/zosyn initially, though
all microbiology negative (blood x 3, urine, no sputum
obtained). He was maintained on zosyn or intermittently unasyn
while at . TTE on showed LVEF , akinetic
motion of anteroseptal wall of LV with moderate LV size increase
left atrial mild dilation, PA pressure 20, severe TR, trace AR,
normal architecture to tricuspid valve. He had transaminitis and
hyperbilirubinemia, and RUQ U/S showed ascites, presumed
secondary to congestive hepatopathy. His creatinine improved
with diuresis. He had an intermittent low grade O2 requirement
intermittently, no more than 2L NC. During his hospitalization,
he was seen by palliative care and decided his code status would
be DNR/DNI. His cardiac rhythm oscillated between sinus
tachycardia and atrial fibrillation, and he was maintained on
amiodarone 200 mg daily, but beta blockade was held due to
hypotension. He was able to be weaned off phenylephrine on .
There was concern for dysphagia, but a barium swallow was
satisfactory and he was advanced to a regular diet. GI was
consulted regarding removal of his G-tube, but bedside removal
was deferred until INR < 1.3. His INR did drop to this level,
but then rose again when Coumadin was restarted. Regarding his
volume status, he was able to be maintained on 40 mg torsemide
BID. He states his dry weight is 125 pounds. He was able to
ambulate with and take his meal in chairs prior to transfer.
## PAST MEDICAL HISTORY:
# CAD s/p CABG c/b mediastinal re-exploration for
bleeding
# NSTEMI (unclear from records whether he was stented at
that time)
# systolic CHF (EF in with small apical thrombus
on echo)
# HTN
# embolic parietal CVA with dysphagia, requiring G-tube plaement
during hospitalization for tube feeds
# afib
# COPD
# chronic anemia
# basal cell carcinoma of scalp
## FAMILY HISTORY:
No premature coronary artery disease
## PHYSICAL EXAM UPON ADMISSION:
Vitals - 97.8 93/69 118 20 96% RA
Gen - No acute distress, cachectic, resting comfortably in bed
HEENT - MM somewhat dry, sclera anicteric
Neck - JVP visible at TMJ, no adenopathy
Chest - Rales at L lung base, otherwise clear to auscultation
with equal air entry
## ABDOMEN:
Abdominal hernia that is nontender, G-tube with mild
erythema around it that is not warm or painful, +BS, no
organomegaly, no fluid wave
## GROIN:
Stretched skin with erythema that is not pruritic
## EXTREMITIES:
Woody skin changes without venous stasis obvious,
warm at thigh, distal extremities slightly cool, intact
peripheral pulses
## NEURO:
AOx3, moving all extremities with purpose
## EKG, :
Atrial fibrillation or atrial flutter with variable block. Low
limb lead
voltage. Intraventricular conduction delay. Inferior wall
myocardial
infarction. Early R wave progression. ST-T wave abnormalities.
Compared to
the previous tracing of , then there was atrial
fibrillation at a slower rate with a single ventricular
premature beat. Changes of inferior and lateral myocardial
infarction appear to be persist. Clinical correlation is
suggested.
KUB,
## FINDINGS:
There are no abnormally dilated loops of large or small bowel.
There is no
free intraperitoneal air. Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or
radiopaque foreign bodies.
## BRIEF HOSPITAL COURSE:
Mr is a year old male with a history of class IV
CHF with an EF and right heart failure who was
transferred from after a 9-day wait
for CCU bed for management of acute-on-chronic sCHF.
The patient presented with volume overload and SOB at
. Echo revealed EF of at on . Patient
was treated for cardiogenic shock with a phenylephrine drip and
IV diuresis. He presented to us with continued volume overload
with acute exacerbation of CHF. The trigger for his worsening
heart failure is unclear. He was treated with torsemide 40 mg PO
BID at and he became euvolemic with improved symptoms. We
held his beta blocker given his poor cardiac ouput and also held
his ace inhibitor given soft blood pressures. We also started
the patient on sildenafil in an effort to reduce afterload for
the RV and digoxin to improve cardiac output. Lactate was
slightly elevated at 2.2 upon transfer but down trended during
admission.
A goals of care meeting was held on and the patient and
his family decided to pursue more comfortable measures. They
were not amenable to right heart catheterization and ionotropy
to improve cardiac function. Pt was transitioned to inpatient
hospice. We continued medicatios to keep the patient comfortable
but discontinued medications that were not needed. The patient
expired on .
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
5. Potassium Chloride 20 mEq PO DAILY
6. Warfarin 6 mg PO DAILY16
7. Lisinopril 2.5 mg PO DAILY
8. Metoprolol Succinate XL 12.5 mg PO BID
9. Torsemide 40 mg PO DAILY
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17176117", "visit_id": "23076003", "time": "2164-02-12 00:00:00"} |
11127641-DS-19 | 911 | ## ALLERGIES:
Patient recorded as having No Known Allergies to Drugs
## HISTORY OF PRESENT ILLNESS:
Previously healthy y/o female who presented to an OSH
with 5 day history of fever, headache and abdominal pain. During
her work up at she was noted to have a CT scan with "air
in the venous and arterial system" and transferred for air in
the intracranial arteries. A repeat CT scan was performed and
showed no air.
Pt states that 5 days ago she noticed she had a headache,
"pressure sensation on top of my head," with no radiation that
went away with acetaminophen. 2 days after this she noticed the
same, constant pressure headache with fever (recorded to be
101.3 at home). Pt also noticed some diffuse abdominal pain with
nausea.
Pt denies any neck stiffness, diarrhea, recent tick bites,
chest pain, SOB, travel history.
In the ER pt had an episode of non-bloody emesis following
morphine administration. Pt also received a 4l NS bolus, lumbar
puncture, blood smears for parasites, bld cx, urine cx, U/A, CSF
cx. Pt was also seen in the ER by Neurology who agreed with
plan.
Upon reaching the floor the pt triggered for a SBP of 88.
Pt mentating well with good urine output during hypotensive
episode. Per pt her baseline is 110s, 100s at .
## PHYSICAL :
VS - Temp , BP , HR 57, R 18, O2-sat 97% RA
GENERAL - Well-appearing woman in NAD, comfortable, appropriate
HEENT - PERRLA, EOMI, sclerae anicteric
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 - RRR, no MRG, nl S1-S2
ABDOMEN - Soft, NT/ND, slight facial grimacing noted on deep
palaption, slight rebound noted, -psoas sign, -obturator sign,
-rosvings.
EXTREMITIES - 2 + peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-VIII, XI, XII intact, muscle
strength throughout, sensation grossly intact throughout,
DTRs 2+.
## IMPRESSION:
No evidence of cholelithiasis or cholecystitis.
2. CTA HEAD W&W/O C & RECONS
## HEAD CT:
There is no evidence of hemorrhage, edema, masses, mass
effect, or infarction. The ventricles and sulci are normal in
caliber and configuration. No fractures are identified. The
arteries of the brain are patent with no evidence of stenosis.
There is no evidence of aneurysm formation or other vascular
abnormality.
## BRIEF HOSPITAL COURSE:
Previously health y/o Female admitted for fevers, photophobia
headaches most likely secondary to Ehrlichiosis with Babesia
labs pending.
## ##. FEVER WITHOUT SOURCE:
Patient was admitted for fevers,
photophobia and headache. Upon admission to the hospital pt was
suspected of having Lyme meningitis and was placed on
Ceftriaxone. After an LP was unremarkable for infection Ms.
antibiotic regimen was switched to Doxycycline. An
infectious work up was performed and revealed negative blood
cultures, Lyme titer, CMV, EBV IgM and peripheral smear. An
infectious disease consult was obtained after pt was noted to be
undergoing hemolysis. Based on the pt's lab evidence of
hemolysis, transaminitis Infectious disease recommended a work
up of Ehrlichia versus Babesiosis was obtained. At time of
discharge lab work was still pending, pt was given Doxycycline
for presumed Ehrlichiosis, she will undergo repeat labs with her
PCP to evaluate if she is still undergoing hemolysis. If she
continues to hemolyze or her Babesia labs turn positive we will
change antibiotic regimen to atovaquone and azithromycin.
## ##. HEADACHE:
Upon presentation to the ER pt did endorse a
pressure sensation headache, there was an initial concern for
Lyme meningitis, an LP was performed and was unremarkable. Prior
to discharge pt did experience another headache, full
examination revealed no intracranial pressure or neurological
deficits and was terminated with Ibuprofen. The timing of the
headache with the fevers raises our suspicion that this part of
her underlying infection. Would recommend continuing to follow
headache pattern to see if they resolve with the fevers.
## ##. TRANSAMINITIS:
Upon admission pt's AST/ALT were noted to be
elevated with normal hepatic function. An abdominal U/S was
obtained and showed no evidence of biliary disease. Upon
discharge Ms. AST/ALT trended down, it is likely
that her current transaminitis is part of her infectious
syndrome. Would recommend repeat liver function tests in 4 weeks
to monitor hepatic function.
## MEDICATIONS ON ADMISSION:
ASA 81mg daily
Vitamin B12
Manganese
Ca Citrate + Vit D
Fish Oil
## DISCHARGE MEDICATIONS:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
## 2. HEXAVITAMIN TABLET SIG:
One (1) Tablet PO once a day.
## 3. MANGANESE TABLET SIG:
One (1) Tablet PO once a day.
4. Calcium 500 mg Tablet Sig: One (1) Tablet PO once a day.
5. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a
day.
6. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 25 doses: Please take medication twice
a day, your last antibiotic day will be .
Disp:*25 Capsule(s)* Refills:*0*
7. Outpatient Lab Work
Please check Hct and liver function tests on
## DISCHARGE INSTRUCTIONS:
You were admitted to the hospital with headache, fever which was
most likely due to a viral infection. During your hospital stay
your headache and your fever got better and you were able to
eat.
If your headache returns or you notice some weakness in your
arms or legs, please return to the ER. Please set up an
appointment to see your PCP .
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "11127641", "visit_id": "26317412", "time": "2149-08-13 00:00:00"} |
17123392-DS-24 | 1,736 | ## ALLERGIES:
Nsaids / Aspirin / Influenza Virus Vaccine
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
RIJ placement and removal
tube placement and removal
Rectal tube placement and removal
PICC line placement and removal
## HISTORY OF PRESENT ILLNESS:
Ms. is a with cirrhosis of unproven etiology, h/o
perforated duodenal ulcer who has had weakness and back
pain with cough and shortness of breath for 2 days. She has
chronic low back pain, but this is in a different location. She
also reports fever and chills. She reports increasing weakness
and fatigue over the same amount of time. She is followed by
who saw her at home and secondary to hypotension and hypoxia
requested she go to ED.
.
In the ED, initial vs were: afebrile, 114 18 and o2 sat
unable to be read. CT of Torso showed pneumonia, but no
abdominal pathology. She was seen by surgery. She was found to
be significantly hypoxic and started on NRB. A Right IJ was
placed. She was started on Levophed after a drop in her
pressures.
.
In the MICU she is conversant and able to tell her story.
## PAST MEDICAL HISTORY:
1. asthma -does not use inhalers
2. HTN -off meds for several years
3. rheumatoid arthritis -seronegative
4. chronic severe back pain
5. s/p 4 C-sections.
6. History of secondary syphilis, treated.
7. Polysubstance abuse, notably cocaine but no drug or alcohol
use for at least past 2 months
8. Depression
9. Pulmonary hypertension- severe on cardiac cath . Restrictive lung disease
11. Seizures in childhood
12. Cirrhosis by liver biopsy . Etiology as yet unknown
13. duodenal ulcer s/p surgical repair . in
## PHYSICAL EXAM:
On admission:
T 100.4 HR 107 BP 97/39 R 41 O2 sat 99% on NRB
## GENERAL:
Alert, oriented, moderate respiratory distress
## HEENT:
Sclera anicteric, dryMM, oropharynx clear
## NECK:
supple, JVP not elevated, no LAD
## LUNGS:
rhonchi and crackles in bases, LLL with egophany,
increased fremetus.
## CV:
Tachy rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
## ABDOMEN:
soft, diffusely tender, non-distended, bowel sounds
present, healing midline ex-lap wound (dehiscence on caudal end
but without erythema, drainage)
## EXT:
Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
## CT CHEST, ABD, PELVIS:
IMPRESSION:
1. No etiology for abdominal pain identified. No free air is
noted within
the abdomen.
2. Interval increase in diffuse anasarca and bilateral pleural
effusions,
small on the right and small-to-moderate on the left.
Compressive atelectasis and new bilateral lower lobe pneumonias.
3. Interval improvement in the degree of mediastinal
lymphadenopathy.
4. Interval development of small pericardial effusion. No CT
findings to
suggest tamponade.
.
## TTE:
The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). The estimated
cardiac index is borderline low (2.0-2.5L/min/m2). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). The right ventricular free wall is
hypertrophied. The right ventricular cavity is markedly dilated
with severe global free wall hypokinesis. There is abnormal
septal motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are structurally
normal. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is mild-moderate
tricuspid regurgitatiaon. There is severe pulmonary artery
systolic hypertension. There is a small, circumferential
pericardial effusion without echocardiographic signs of
tamponade.
Compared with the prior study (images reviewed) of , the
overall findings are similar.
.
CT abd, pelvis: IMPRESSION:
1. Anasarca. Increased bilateral pleural effusions, small to
moderate, right greater than left. Trace pericardial fluid.
2. Increased left lower lobe collapse/consolidation. Right
basilar
atelectasis has also increased.
3. New ascites. No free air.
4. Dilated fluid-filled colon and rectum. No wall thickening to
suggest
colitis.
5. No evidence of small bowel obstruction.
.
Bilat upper extremities venous ultrasound: IMPRESSION:
Non-occlusive right subclavian deep vein thrombosis.
.
## CTA CHEST:
IMPRESSION:
1. No pulmonary embolism to the subsegmental level.
2. Anasarca. Moderate-to-large left and moderate right pleural
effusion.
Small pericardial effusion.
3. Unchanged right ventricle and right atrium enlargement since
. Enlarged main pulmonary artery could be due to pulmonary
hypertension.
4. Complete collapse of the left lower lobe, pneumonia cannot be
ruled out. Right basilar atelectasis.
.
## KUB:
IMPRESSION:
Unchanged borderline distended colon. No evidence of small-bowel
obstruction or ileus.
## BRIEF HOSPITAL COURSE:
This is a with severe pulmonary hypertension, h/o duodenal
perf s/p surgical repair , cirrhosis of unknown etiology
and h/o polysubstance abuse who presented with septic shock
secondary pneumonia with respiratory distress.
.
# Septic Shock/ pneumonia: fever, hypotension, tachycardia,
hypoxia, leukocytosis, with LLL infiltrate. Initially, pt was
treated for both health-care associated pneumonia and possible
C. Diff infection given WBC 60 on admission. However, C diff
treatment was stopped after patient tested negative x3. She
completed a 7 day course of Vancomycin/Zosyn on for
pneumonia. She did initially require non-rebreather in the ICU
but for the last week prior to discharge, she has had stable O2
sats to mid 90's on nasal cannula. She did also require pressors
for the first several days of this hospitalization but was
successfully weaned off pressors approximately 1 wk prior to
discharge. At the time of discharge, she is maintaining stable
BP's 100s-110s/doppler.
Due to repeated IVF boluses for hypotension during this
admission, the pt developed anasarca and at the time of
discharge is being slowly diuresed with Lasix 10 IV daily.
.
# Ogilvies pseudo-obstruction: The pt experience abd pain and
distention with radiologic evidence of dilated loops of small
bowel and large bowel during this hospitalization. There was
never any evidence of a transition point of stricture. Both a
rectal and NGT were placed for decompression. The pts symptoms
and abd exam improved during the days prior to discharge and at
the time of discharge, she is tolerating a regular PO diet and
having normal bowel movements.
.
# Chronic back pain: The pt has a long h/o chronic back pain.
She was treated with IV morphine here for acute on chronic back
pain likely exacerbated by bed rest and ileus. At discharge, she
was transitioned to PO morphine.
.
# Cirrhosis: The etiology of this is unknown but the pt has
biopsy proven cirrhosis from liver biopsy. This likely
explains her baseline coagulopathy and hypoalbuminemia <2 here.
She needs to have outpt f/u with hepatology. She has no known
complications of cirrhosis at this time.
.
# RUE DVT: The pt has a RUE DVT seen on U/S associated
with RIJ CVL which was placed in house. She was started on a
heparin gtt which was transitioned to coumadin prior to
discharge. At discharge, her INR is 2.0. She should have follow
up lab work on
.
# Of note, at discharge, the pt had several healing boils on her
inner upper thighs thought to be trauma from her foley
rubbing against the skin. No further treatment was thought to be
neccessary for these.
## MEDICATIONS ON ADMISSION:
CLOBETASOL - 0.05 % Cream - apply to affected area twice a day
as
needed
GABAPENTIN [NEURONTIN] - 800 mg Tablet - 1 Tablet(s) by mouth
three times a day
METOPROLOL TARTRATE - 25 mg Tablet - Tablet(s) by mouth
twice a day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule,
Delayed Release(E.C.)(s) by mouth once a day
OXYCODONE - 5 mg Capsule - Capsule(s) by mouth q 6 hours
PHYSICAL THERAPY - - Dx: Evaluation and
Management of motor skills.
TRAMADOL - 50 mg Tablet - 1 Tablet(s) by mouth twice a day as
needed for pain
TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth hs
Medications - OTC
DOCUSATE SODIUM - 50 mg/5 mL Liquid - 1 teaspoon by mouth twice
a
day as needed
MAGNESIUM OXIDE - 400 mg Tablet - 2 Tablet(s) by mouth twice a
day
## DISCHARGE MEDICATIONS:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q6H (every 6 hours).
2. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical BID (2
times a day).
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QDAY () as needed for
back pain: Please wear on skin 12 hrs then have 12 hrs with
patch off.
4. Hemorrhoidal Suppository 0.25 % Suppository Sig: One (1)
suppository Rectal once a day as needed for pain.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
6. Outpatient Lab Work
Please have you INR checked . The results should
be sent to your doctor at rehab.
## 7. MULTIVITAMIN TABLET SIG:
One (1) Tablet PO once a day.
8. Morphine 10 mg/5 mL Solution Sig: mg PO every four (4)
hours as needed for pain.
9. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
.
## DISCHARGE DIAGNOSIS:
Healthcare Associated Pneumonia
Colonic Pseudo-obstruction
Severe pulmonary hypertension
Cirrhosis
HTN
Chronic back pain
Right upper extremity DVT
## DISCHARGE CONDITION:
Good. O2 sat high 90's on 3L NC. BP stable 100s-110s/doppler.
Patient tolerating regular diet and having bowel movements. Not
ambulatory.
## DISCHARGE INSTRUCTIONS:
You were admitted with a pneumonia which required a stay in our
ICU but did not require intubation or the use of a breathing
tube. You did need medications for a low blood pressure for the
first several days of your hospitalization.
While you were here, you also had problems with your intestines
that caused them to stop working and food to get stuck in your
intestines. We treated you for this and you are now able to eat
and move your bowels.
You got a blood clot in your arm while you were here. We started
you on IV medication for this initially but have now
transitioned you to oral anticoagulants. Your doctor need
to monitor the levels of this medication at rehab. You will
likely need to remain on this medication for 3 months.
.
Please follow up as below. You need to see a hepatologist (liver
doctor) within the next month to follow up on your diagnosis of
cirrhosis.
.
Your list of medications is attached.
.
Please call your doctor or return to the hospital if you have
fevers, shortness of breath, chest pain, abdominal pain,
vomitting, inability to tolerate food or liquids by mouth,
dizziness or any other concerning symptoms.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "17123392", "visit_id": "25251600", "time": "2189-03-24 00:00:00"} |
18852201-RR-14 | 111 | ## INDICATION:
with right sided adnexal tenderness on exam// ? ? ovarian
torsion ?
## FINDINGS:
The uterus is anteverted and measures 6.8 x 3.3 x 3.8 cm. Incidental note is
made of a small fibroid along the anterior uterus measuring approximately 0.5
cm. The endometrium is homogenous and measures 1 mm.
Due to acute, localized pain symptoms, spectral and color Doppler of the
ovaries was performed. There was normal arterial and venous flow demonstrated
within the ovaries.
The left ovary appears normal. The right ovary appears normal with multiple
follicles. There is no free fluid.
## IMPRESSION:
1. No evidence of ovarian torsion. No free fluid.
2. Small uterine fibroid.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18852201", "visit_id": "N/A", "time": "2173-05-11 19:53:00"} |
12114398-RR-18 | 339 | ## INDICATION:
ASSESSMENT OF THE PATIENT WITH SUSPECTED PLEURAL EFFUSION
## FINDINGS:
Bilateral thyroid nodules are up to 12 mm. There is diffuse enlargement of the
thyroid. Largest nodule is at the inferior pole of the left thyroid, 18 mm.
Anterior mediastinal overall 2.4 x 1.7 cm lesion is low in density,
approaching 1 Hounsfield unit. Most likely this lesion represents at cyst. No
mediastinal, hilar or axillary lymphadenopathy is present. Heart size is
enlarged. Extensive Coronary calcifications are noted. No pericardial effusion
is seen.
Small right pleural effusion is present. Minimal left pleural fluid versus
pleural thickening is demonstrated. Small amount of ascites is noted in the
upper abdomen, partially imaged as well as sludge within the gallbladder. In
addition there is distension of the common bile duct, with no evidence of
obstruction, up to 14 mm, potentially representing choledochal seal.
There is partial imaging of dilatation of the abdominal aorta, up to 3.6 cm,
all those findings to be discussed in details in the CT abdomen and the
corresponding report
Airways are patent to the subsegmental level bilaterally with minimal
narrowing of the superior trachea by the thyroid. Right basal opacity is a
adjacent to the pleural fluid and most likely represent atelectasis. Right
apical subpleural nodule, series 102, image 13 is 4 mm in diameter. No
additional masses are consolidations seen. Left lower lobe cyst is present.
There are no lytic or sclerotic lesions worrisome for infection or neoplasm.
## IMPRESSION:
1. Small right pleural effusion with associated compressive atelectasis in the
right lower lobe.
2. Nonenhancing anterior mediastinal mass with simple internal fluid density,
likely a cyst, such as a pericardial or thymic cyst.
3. Hypodense thyroid nodules measuring up to 15 x 10 mm on the right and 17 x
12 mm on the left can be further evaluated on a non urgent/out patient thyroid
ultrasound.
4. Mildly enlarged heart with diffuse coronary artery calcifications and mild
calcification of the aortic valve.
Please refer to separate report for intra-abdominal findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12114398", "visit_id": "21034808", "time": "2148-12-22 21:01:00"} |
14437403-RR-114 | 153 | ## INDICATION:
woman with malignant ascites.
## PROCEDURE:
The risks, benefits, and alternatives to the procedure were
described to the patient, who gave written informed consent.
A preprocedure timeout was performed using three patient identifiers.
A preliminary planning CT was performed, which again demonstrated a large
amount of loculated ascites.
The patient was prepped and draped in the usual sterile fashion. Lidocaine
was used as local anesthetic. Under CT guidance, needle was
advanced into a large fluid collection in the left abdomen. A wire
was then advanced through the needle, and exchanged for a 6 pigtail
catheter. The wire was removed, and the catheter was attached to a collection
device. Approximately 4.5 liters of fluid were removed.
The patient tolerated the procedure well, without immediate post-procedural
complication.
Dr. attending physician, was present for, and performed the
procedure in its entirety.
## IMPRESSION:
Uneventful CT-guided paracentesis yielding 4.5 liters of fluid.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14437403", "visit_id": "N/A", "time": "2188-07-24 09:04:00"} |
14467216-RR-8 | 962 | ## :
Cardiology Staff: , MD
## GENDER:
Female Radiology Staff: , MD
## STATUS:
Outpatient Nursing Support: , RN
## WEIGHT (LBS):
200 Injection Site: left antecubital vein
## RHYTHM:
Sinus rhythm Creatinine (mg/dl): 0.9
## CMR MEASUREMENTS:
Measurement Normal Range
Left Ventricle
LV End-Diastolic Dimension (mm) *64 <55
LV End-Diastolic Dimension Index (mm/m2) 31 <33
LV End-Systolic Dimension (mm) 55
LV End-Diastolic Volume (ml) ***247 <143
LV End-Diastolic Volume Index (ml/m2) **119 <78
LV End-Systolic Volume (ml) 140
LV Stroke Volume (ml) 107
LV Stroke Volume Index (ml/m2) 51
LV Ejection Fraction (%) *43 >=56
LV Mass (g) 142
LV Mass Index (g/m2) *68 <60
Basal wall thickness (mm) 9 <10
Basal infero-lateral wall thickness (mm) 8 <9
Basal infero-lateral wall motion Hypokinetic
Basal inferior wall motion Severely hypokinetic
Mid infero-lateral wall motion Severely hypokinetic
Mid inferior wall motion Akinetic
Basal infero-lateral late gadolinium
enhancement 76-100% (ischemic type)
Basal inferior late gadolinium
enhancement 76-100% (ischemic type)
Mid infero-lateral late gadolinium
enhancement 76-100% (ischemic type)
Mid inferior late gadolinium
enhancement 76-100% (ischemic type)
Q-Flow Aortic Net Forward Stroke
Volume (ml) 97
Q-Flow Aortic Total Stroke Volume (ml) 98
Q-Flow Aortic Cardiac Output (l/min) 7.4
Q-Flow Aortic Cardiac Index (l/min/m2) 3.5
LV Effective Forward Ejection Fraction (%) **39 >=56
Right Ventricle
RV End-Diastolic Volume (ml) 153
RV End-Diastolic Volume Index (ml/m2) 74 47-103
RV End-Systolic Volume (ml) 55
RV Stroke Volume (ml) 98
RV Stroke Volume Index (ml/m2) 47
RV Ejection Fraction (%) 64 >=49
Q-Flow Pulmonary Net Forward Stroke Volume (ml) 98
Q-Flow Pulmonary Total Stroke Volume (ml) 98
Qp/Qs 1.01 0.8-1.2
Atria
Left Atrial Dimension (Axial) (mm) *41 <40
Left Atrial Length (4-Chamber) (mm) 48 <52
Left Atrial Length (2-Chamber) (mm) 48
Right Atrial Dimension (4-Chamber) (mm) *57 <50
Great Vessels
Ascending Aorta Diameter (mm) 30 <35
Ascending Aorta Diameter Index (mm/m2) 14 <21
Transverse Aorta Diameter (mm) 26
Transverse Aorta Diameter Index (mm/m2) 12
Descending Aorta Diameter (mm) 20 <25
Descending Aorta Index (mm/m2) 10 <15
Abdominal Aorta Diameter (mm) 21
Abdominal Aorta Diameter Index (mm/m2) 10
Main Pulmonary Artery Diameter (mm) 24 <27
Main Pulmonary Artery Diameter Index (mm/m2) 12 <15
Coronary Artery Grafts Patent
Valves
Aortic Valve Morphology Trileaflet
Aortic Valve Excursion Normal
Aortic Valve Area (cm2) 3.3 >=2
Aortic Valve Area Index (cm2/m2) 1.6
Aortic Valve Regurgitant Volume (ml) 1
Aortic Valve Regurgitant Fraction (%) 1 <5
Mitral Valve Regurgitation (Visual) Present
Mitral Valve Regurgitant Volume (ml) 9
Mitral Valve Regurgitant Fraction (%) *8 <5
Pulmonary Valve Regurgitant Volume (ml) 0
Pulmonary Valve Regurgitant Fraction (%) 0 <5
Tricuspid Valve Regurgitant Volume (ml) 0
Tricuspid Valve Regurgitant Fraction (%) 0 <5
Pericardium
Pericardial Thickness (mm) 2 <4
* Mildly abnormal | ** Moderately abnormal | *** Severely abnormal
## STRUCTURE
" T1-WEIGHTED (BLACK BLOOD):
Dual-inversion T1-weighted fast spin echo images
were acquired in 5-mm contiguous axial slices to evaluate cardiac and vascular
anatomy.
" Aorta Views: Dedicated T1-weighted black blood images and SSFP images were
acquired to evaluate the proximal, transverse, and descending aorta.
## FUNCTION
" CINE SSFP:
Breath-hold SSFP cine images were acquired in 8-mm slices in the
4-chamber, 3-chamber, 2-chamber, and short axis orientations.
" Cine SSFP (Additional Aortic Valve Views): A short-axis series was acquired
at the level of the aortic valve.
## FLOW
" AORTIC VALVE FLOW:
Phase-contrast cine images were acquired transverse to
the proximal ascending aorta to quantify through-plane flow.
" Pulmonary Valve Flow: Phase-contrast cine images were acquired transverse
to the main pulmonary artery to quantify through-plane flow.
##
VIABILITY
" LGE (3D):
Late gadolinium enhancement (LGE) images were acquired using a
navigator-gated 3D ultrafast gradient echo inversion-recovery sequence with
spectral fat saturation pre-pulses 15 minutes after injection of a total of
0.1 mmol/kg (17 mL) Gd-BOPTA (Multihance).
" LGE (3D PSIR): Late gadolinium enhancement (LGE) images were acquired using
a navigator-gated 3D phase sensitive inversion-recovery (PSIR) sequence with
spectral fat saturation pre-pulses 15 minutes after injection of a total of
0.1 mmol/kg (17 mL) Gd-BOPTA (Multihance).
## LEFT VENTRICLE
" LV CAVITY SIZE:
Moderately increased
" LV ejection fraction: Mildly depressed
" LV mass: Mildly increased
" Basal infero-lateral wall motion: Hypokinetic
" Basal inferior wall motion: Severely hypokinetic
" Mid infero-lateral wall motion: Severely hypokinetic
" Mid inferior wall motion: Akinetic
" Basal infero-lateral late gadolinium enhancement: 76-100% (ischemic type)
" Basal inferior late gadolinium enhancement: 76-100% (ischemic type)
" Mid infero-lateral late gadolinium enhancement: 76-100% (ischemic type)
" Mid inferior late gadolinium enhancement: 76-100% (ischemic type)
## RIGHT VENTRICLE
" RV CAVITY SIZE:
Normal
" RV ejection fraction: Normal
" Intra-cardiac shunt: None present
## ATRIA
" LA SIZE:
Normal
" RA size: Mildly enlarged
## GREAT VESSELS
" ASCENDING AORTIC DIAMETER:
Normal
" Main pulmonary artery diameter: Normal
## VALVES
" AORTIC VALVE MORPHOLOGY:
Trileaflet
" Aortic stenosis: No
" Mitral regurgitation jet: Present
" Mitral regurgitation: Mild
## ADDITIONAL INFORMATION/FINDINGS:
None.
## NON-CARDIAC FINDINGS:
Bibasilar atelectasis.
## IMPRESSION:
Mild biatrial enlargement. Moderately increased left ventricular cavity size
with normal wall thickness and mildly increased mass. Mild left ventricular
systolic dysfunction (LVEF 43%) with akinesis of the mid inferior wall and
hypokinesis of the mid and basal inferolateral wall and the basal inferior
wall. Normal right ventricular cavity size with normal systolic function.
Transmural late gadolinium enhancement of the mid and basal inferior and
inferolateral walls, consistent with fibrosis/scar with a low probability of
recovery of function after revascularization. Normal ascending aorta,
descending aorta and main pulmonary artery diameters. No aortic stenosis or
regurgitation. Mild mitral regurgitation with a well-seated, normally
functioning mechanical mitral valve prosthesis. No tricuspid regurgitation.
Trace pericardial effusion.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14467216", "visit_id": "N/A", "time": "2160-09-26 12:55:00"} |
13305547-DS-9 | 900 | ## HISTORY OF PRESENT ILLNESS:
YOF with type I DM x years with PVD, CAD s/p CABG, usual
hypotension who was in until 1 week PTP when she noticed
the developed of icreased tension and "being wired" which
manifested itself as increased impatience. No recent social
stressors. On the night of presentation she developed tremors,
checked her BP which was 180/102-> 208/52 on her home monitor, P
= 65 which is abnormal for her as she usually has hypotension.
This prompted her to come to the ED. Upon arrival to the ED her
tension decreased but she felt as though her tremors increased.
No new medications. Six to 8 weeks she d/c'ed her cymbalta,
adderral, vitamin D and calcium. She has never experienced this
before. She saw Dr. week and her BP was 110/45. The
patient has checked her BP at home in the past around 2 months
ago when she would have a BP of 80/40 in the morning with a BP
of 150s/60s. No other new medication. No foreign travel. No
strange foods. Tremors resolved without intervention in the ED.
Upon arrival to the floor she feels back to baseline and would
like to go home. BS have been at 50 all day despite eating all
day so she took half of her insulin at bed time.
.
98.6 76 186/56 15 100
.
-Constitutional: [X]WNL []Weight loss []Fatigue/Malaise []Fever
[]Chills/Rigors []Nightweats []Anorexia
-Eyes: [X]WNL []Blurry Vision []Diplopia []Loss of Vision
[]Photophobia
-ENT: [X]WNL []Dry Mouth []Oral ulcers []Bleeding gums/nose
[]Tinnitus []Sinus pain []Sore throat
-Cardiac: [X]WNL []Chest pain []Palpitations edema
[]Orthopnea/PND []DOE
-Respiratory: [X]WNL []SOB []Pleuritic pain []Hemoptysis []Cough
## PAST MEDICAL HISTORY:
- DM I on insulin pump ranging 0.3-0.8units/hour basal rate, c/b
neuropathy and retinopathy
- PAD, s/p R fem-pop vein graft s/p urokinase
vein patch angioplasty of R fem-pop bypass in .
- NSTEMI in the setting of DKA in
- Hypothyroidism
- HSV2
- Fatigue with question of autonomic disorder but this improved
with discontinuation of the cymbalta.
- S/p vitrectomy and cataract
- Off pump coronary artery bypass graft x1 (left internal
mammary artery > left anterior descending)
## FAMILY HISTORY:
father had first MI at age , brother with SCD in , autopsy
showed extensive 3V CAD. Mother with breast cancer at age
.
## GENERAL:
Well appearing female who appears younger than her
stated age.
## MENTATION:
Alert, speaks in full sentences
## EYES:
NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted
## EARS/NOSE/MOUTH/THROAT:
MMM, no lesions noted in OP
## NECK:
supple, no JVD or carotid bruits appreciated
## RESPIRATORY:
Lungs CTA bilaterally without R/R/W
## CARDIOVASCULAR:
RRR, nl. S1S2, SEM at LUSB
## GASTROINTESTINAL:
soft, NT/ND, normoactive bowel sounds, no
masses or organomegaly noted.
## SKIN:
no rashes or lesions noted. No pressure ulcer
## EXTREMITIES:
No C/C/E bilaterally, 2+ radial, DP and pulses
b/l.
## LYMPHATICS/HEME/IMMUN:
No cervical, supraclavicular, axillary or
inguinal lymphadenopathy noted.
## -MENTAL STATUS:
Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
No foley catheter/tracheostomy/PEG/ventilator support/chest
tube/colostomy
## PSYCHIATRIC:
At first pleasant and appropriate then became more
belligerent.
## ECG:
SR at 94 bpm low voltage, pseudonormalization of T waves in
leads V5 to V6.
## HYPERTENSIVE URGENCY:
We suspect the patient may have been
feeling symptomatic hypertension possibly caused by prolonged
episode of hypoglycemia. As her glucose corrected her
hypertension resolved. It is unclear why the patient had an
episdoe of hypoglycmeia, but she has a UA and blood cultures to
look for infection. She also got TnI neg x 2. TFT's were in
normal range. I discussed with her the work-up for secondary
hypertension which will be deferred for now unless she has any
recurrent hypertension. She was monitored for a number of hours
and had repeated BP's that were in normal range. Upon discharge
her BP was 120/55. Her glucose monitor also showed readings in
normal range as well. She will f/u with her PCP and with
after discharge. She will monitor her BP's daily and was
instructed when to return to the ER for evaluation.
.
## DMI:
(well controlled with HgbA1C = 7.0) Managed with pump.
.
CAD/PVD s/p CABG and fem pop bypass:
- continued ASA/plavix
- continued statin
.
## MEDICATIONS ON ADMISSION:
Confirmed with patient on admission
Atorvastatin 80 mg Tablet 1 Tablet(s) by mouth DAILY (Daily)
Modify
Levoxyl 125 mcg qd
Plavix 75 mg
ASA 81 mg qd
Insulin Aspart [Novolog] Dosage uncertain
No herbal supplements
## DISCHARGE MEDICATIONS:
1. Insulin Lispro 100 unit/mL Solution Sig: as directed
Subcutaneous ASDIR (AS DIRECTED).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
## DISCHARGE INSTRUCTIONS:
You were admitted with transient hypertension. Please monitor
your blood pressure once a day in the morning after waking and
before breakfast or if you have symptoms of headache, dizziness,
or chest pain. If you have repeated systolic(top number >150)
please call your doctor.
We have made no changes to your medications. As we discussed,
please contact your outpatient providers tomorrow to establish
follow up plans.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13305547", "visit_id": "25206742", "time": "2189-06-17 00:00:00"} |
11707694-RR-15 | 97 | PORTABLE AP CHEST X-RAY
## INDICATION:
Patient with new left PICC line placement.
## FINDINGS:
New left subclavian line is in adequate position ending in mid SVC. ET tube
is 4.6 cm above carina. NG tube has been removed and another one has been put
in place; the distal end is not included in the study. Mild pulmonary edema
has slightly worsen. Bilateral pleural effusions and atelectasis are stable.
Mild cardiomegaly is stable. There is no pneumothorax.
## CONCLUSION:
1. Left subclavian line is in adequate position. There is no complication.
2. Mild pulmonary edema has worsen.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11707694", "visit_id": "26598235", "time": "2137-04-05 14:35:00"} |
15546548-RR-30 | 132 | ## REASON FOR EXAMINATION:
Evaluation of the ET tube placement.
PORTABLE AP CHEST RADIOGRAPH WAS COMPARED TO PRIOR STUDY OBTAINED ON , AT 6:07 A.M.
The ET tube tip is 2.5 cm above the carina, appropriate position, especially
given that the current radiograph was obtained when the patient's head was in
flexion. The Dobbhoff tube tip is in stomach/distal duodenum. The left
subclavian line tip is in the proximal right atrium, approximately 2 cm below
the cavoatrial junction.
The cardiomediastinal silhouette is unchanged since the prior examination, but
overall there is decrease in vascular engorgement consistent with improvement
in the volume status. Bibasilar opacities, especially in the left
retrocardiac area, are unchanged consistent with atelectasis. There is no
increase in pleural effusion, and there is no pneumothorax.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15546548", "visit_id": "20642625", "time": "2126-03-31 05:06:00"} |
11019941-DS-9 | 985 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
Ms. is a year old woman G2P1 who is 25 weeks pregnant
woman with MTHFR deficiency and seasonal allergies presenting
with tongue swelling and pleuritic chest pain.
Patient reports that she had dinner around last night
(spaghetti with meatballs, salad, squash; all previously
tolerated, in addition to a watermelon popsicle). After dinner,
she developed a sore throat and minor tongue swelling. No oral
tingling or SOB/CP at that time. She went to sleep. When she
awoke in the morning, she had severe tongue swelling (trouble
managing secretions, lisp when speaking, teeth making
indentations on edge of tongue). At this time, also noticed
chest pain in right shoulder with deep inspiration. No cough or
fevers/chills. Of note, no known allergies and no unusual oral
exposures (no new lipsticks, mouthwash etc). She has history of
eczema as child; she has no history of asthma. She has an
hour-long car ride to and from work, otherwise no prolonged
immobility. Patient not taking an ACE-I. No known family history
of angioedema. She does say that she had a similar sensation
with her prior pregnancy that was attributed to palpitations and
self-resolved.
She went to where she was hemodynamically stable
with O2 sat 100% on RA, swollen tongue, but clear lungs.
## FETAL HEART TONES:
134.
CXR without pathology
Treated with IV Benadryl, Solumedrol 125mg IV, and Pepcid for
allergic reaction. Transferred to further monitoring and
management.
## EXAM:
swollen tongue without swollen lips, speaking comfortably
in complete sentences, clear lungs w/o wheezing, no rash or leg
swelling.
## LABS:
WBC 10.8, Hgb 12.7, BUN/Cr , Ca 9.3,
Imaging notable for: 1) CXR normal 2) b/l: No evidence of
deep venous thrombosis in the bilateral lower extremity veins.
OB was consulted in the ED and recommended airway monitoring and
co-management with the ICU team.
She developed worse tongue swelling at so she was given
Methylprednisilone 60mg IVx1, Benadryl 25mg IV, 1L
with improvement in the swelling.
VS prior to transfer: 97.7F, 74, 100/54, 12, 99%RA
On arrival to the MICU, she feels tired from the Benadryl, but
she thinks her tongue swelling is significantly improved. Her
pleuritic chest pain has resolved. No other complaints at this
time.
## PAST MEDICAL HISTORY:
- IBS
- Methylenetetrahydrofolate reductase deficency
- Intestitial cystitis
- ADHD
- Seasonal allergies
## FATHER:
COPD, asbestosis, agent orange exposure, polycythemia
## MOTHER:
autoimmune disorder
Grandparents had strokes and leukemia.
## GENERAL:
Alert, oriented, no acute distress
## HEENT:
Sclera anicteric, MMM, diffusely enlarged tongue with
teeth markings (improved per report, OP clear
## NECK:
supple, JVP not elevated, no LAD
## LUNGS:
Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
## CV:
Regular rate and rhythm, normal S1 S2, systolic flow murmur
present, no gallops
## ABD:
soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
## EXT:
Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
## NEURO:
CNII-XII intact, strength in b/l.
## PHYSICAL EXAM ON DISCHARGE:
===========================
Alert, oriented, tongue with mild scalloping, no lip or palatal
edema. Speech clear. Well appearing. No rashes.
## IMAGING:
========
BILATERAL LOWER EXT VEINS
No evidence of deep venous thrombosis in the bilateral lower
extremity veins
## BRIEF HOSPITAL COURSE:
Patient is a year old woman, G2P1, who is 25 weeks pregnant
woman with MTHFR deficiency and seasonal allergies presenting
with tongue swelling and pleuritic chest pain due to angioedema.
Of note, patient had consumed a watermelon popsicle, which she
thinks may have triggered her symptoms. Patient was given IV
solumedrol and diphenhydramine with improvement in her symptoms.
After discussion with Allergy and Immunology and the OB team,
the decision was made to discharge patient with cetirizine BID
and a 1-week prednisone taper; she was also given script for
epipen. She was set up with appointments to follow up with her
PCP and and Immunology; and she was discharged home from
the ICU.
## TRANSITIONAL ISSUES:
===================
-f/u with PCP
- with Allergy and Immunology
-Prednisone taper (40mg x2d, 20mg x2d, 10mg x2d then stop. Last
day is .
-Cetirizine 10mg BID
-Follow up: C1 Esterase Inhibitor
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Prenatal Vitamin (prenat.vits,cal,min-iron-folic;<br>prenatal
vit vit-iron fumarate-FA) unknown
oral QD
2. DHA Algal-900 (docosahexanoic acid) unknown oral QD
## DISCHARGE MEDICATIONS:
1. Cetirizine 10 mg PO BID
RX *cetirizine 10 mg 1 tablet(s) by mouth twice a day Disp #*60
## TABLET REFILLS:
*0
2. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 Duration: 1 Dose
RX *epinephrine [Adrenaclick] 0.3 mg/0.3 mL 1 injection once a
day Disp #*1 Package Refills:*0
3. PredniSONE 10 mg PO DAILY
4 tablets on tablets on tablets on
Tapered dose - DOWN
RX *prednisone 10 mg 4 tablet(s) by mouth once a day Disp #*14
## TABLET REFILLS:
*0
4. DHA Algal-900 (docosahexanoic acid) 1 tablet oral QD
5. Prenatal Vitamin
(prenat.vits,cal,min-iron-folic;<br>prenatal vit
vit-iron fumarate-FA) 1 tablet
oral QD
## SECONDARY:
Methylenetetrahydrofolate reductase deficency
Pregnancy
IBS
## DISCHARGE INSTRUCTIONS:
Dear ,
were admitted to
because had tongue swelling.
We are not exactly sure why this happened. It is possible that
had a reaction to a popsicle.
were treated with steroids and antihistamines, with
improvement in your symptoms. We spoke with our allergists who
recommended that continue steroids and take an
antihistamine.
should follow up with your PCP and an allergist, and we have
made appointments for to see both.
are being discharged with prescriptions for the
antihistamine and steroids. should take the antihistamines
until see your allergist.
are being discharged with a prescription for a special
injected for epinephrine. should inject this into your thigh
if develop severe shortness of breath. If use it,
should go immediately to the emergency department.
It was a pleasure to help care for during this
hospitalization.
Sincerely,
Your Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "11019941", "visit_id": "20302688", "time": "2173-11-21 00:00:00"} |
11829192-RR-52 | 114 | ## HISTORY:
Metastatic cancer and shortness of breath.
## FINDINGS:
Right-sided Port-A-Cath is seen with catheter terminating at the cavoatrial
junction. Bilateral pulmonary opacities, multiple, consistent with the
patient's known metastatic disease; difficult to accurately compare to prior
given differences in modality to the prior CT, however, overall, nodular
opacaities appear to have increased in size, and possibly number, worrisome
for worsening metastatic disease. No definite new focal consolidation is
seen. There is no pleural effusion or evidence of pneumothorax. The cardiac
and mediastinal silhouettes are stable. Osseous metastatic disease better
assessed on CT.
## IMPRESSION:
Extensive pulmonary metastases worrisome for progression since the prior CT
from , given differences in modality.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11829192", "visit_id": "21672011", "time": "2150-03-02 17:51:00"} |
13833307-DS-14 | 959 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Laparoscopic Sigmoid Resection for Sigmoid Mass
## HISTORY OF PRESENT ILLNESS:
year old male patient who was refered to Dr. a
colonoscopy which found to have a mass in the sigmoid colon. The
biopsies revealed a polypoid lesion, the appearance of the
lesion was highly suspicious sampling error could have
underestimate the presence of a cancer. He has another polyp at
25 cm, which was removed without incident. He has had a CT scan
of his chest and abdomen, which shows a mass in the sigmoid
colon. The patient presented to for surgical managment of
this mass.
## PAST MEDICAL HISTORY:
HTN, which his wife says is long-standing but which he has not
had treated; he has not seen a doctor in years.
## FAMILY HISTORY:
HTN; poorly treated - per family, patient refused
antihypertensive therapy.
## GENERAL:
No nausea, no vomiting, passing flatus per rectum,
tolerating regular diet, pain well controlled on pain
medications by mouth.
## LUNGS:
Clear to ascultation B/L
## ABD:
soft, nontender, minimal distension
## WOUND:
Laparoscopic sites clean, dry, an intact
## BRIEF HOSPITAL COURSE:
The patient was admitted to the inpatient ward after a
laparoscopic sigmoid colectomy. The patient tolerated this
procedure well. His vital signs were stable throughout his
post-operative . On post-operative day one the patient
tolerated a clear liquid diet and he was started on pain
medications by mouth which he tolerated well. Given his risk for
seizures, the patient was placed on seizure precautions and his
lamotrigine was restarted on post-operative day one, his blood
pressure was monitored and tightly controlled. also on
post-operative day one the patient's JP drain was removed
without issue. The patient was doing very well on post-operative
day two, he was passing flatus, and was started on a regular
diet. The patient ambulated the floor independently and voiding
the morning of post-operative day two after the Foley catheter
had been removed. The patient was discharged on post-operative
day 2 with appropriate medical and surgical discharge
instructions.
## MEDICATIONS ON ADMISSION:
Amlodipine-benzapril daily
Metoprolol 100mf twice daily
Lamotrigine 225mg twice daily
## DISCHARGE MEDICATIONS:
1. lamotrigine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. lamotrigine 200 mg Tablet Sig: One (1) Tablet PO twice a day.
3. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain for 5 days: Please do not drive a car
or drink alcohol or drive a car while taking this medication.
Disp:*50 Tablet(s)* Refills:*0*
## DISCHARGE INSTRUCTIONS:
You were admitted to the hospital after a sigmoid laparoscopic
colectomy for surgical management of your sigmoid colon mass.
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 regaurding these results they will
contact you before this time. You have tolerated a regular diet,
passing gas and your pain is controlled with pain medications by
mouth. You may return home to finish your recovery.
Please monitor your bowel function closely. You may or may not
have had a bowel movement prior to your discharge which is
acceptable, however it is important that you have a bowel
movement in the next days. After anesthesia it is not
uncommon for patients to have some decrease in bowel function
but your should not have prolonged constipation. Some loose
stool and passing of small amounts of dark, old appearing blood
are explected however, if you notice that you are passing bright
red blood with bowel movments 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 does 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,
prolonges loose stool, or constipation.
You have laparoscopic surgical incisions on your abdomen
which are closed with internal surtures and the skin glue
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/gree/yellow/malodorous drainage, increased pain at the
incision, increased warmth of the skin at the incision, or
swelling of the area. Please call the office if you develop any
of these symptoms or a fever. You may go to the emergency room
if your symptoms are severe. You may shower, pat the incisions
dry with a towel do not rub. The small incisions may be left
open to the air. If closed with steri-strips, these will fall
off on their own, please do not remove them. Please no baths or
swimming for 6 weeks after surgery unless told otherwise by Dr.
Dr. .
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": "13833307", "visit_id": "25483004", "time": "2127-05-24 00:00:00"} |
13140001-DS-5 | 1,046 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Redo sternotomy, mitral valve replacement (27mm
mechanical), Maze, left atrial appendage ligation
## HISTORY OF PRESENT ILLNESS:
Mr. is a year old gentleman with a history of mitral
valve prolapse and mitral regurgitation who underwent a mitral
valve repair in at . He has been followed over the years
by serial echocardiogram which have shown worsening mitral
stenosis and regurgitation. He was also diagnosed with new onset
atrial fibrillation several months ago and subsequently started
on Warfarin. In terms of symptoms he reports over time he has
developed fatigue but breathing has been fine and he is able to
perform his usual activities. He is now referred for a
reoperation on his mitral valve.
## PAST MEDICAL HISTORY:
MVP and MR MV repair in at
Moderate MR & MS
, new onset and persistent (on coumadin)
Anxiety
OSA, currently using CPAP
Pulmonary HTN
Systemic HTN
Obesity
Melanocytic nevus
MV repair in at
Jaw surgery as child
## FAMILY HISTORY:
Denies premature coronary artery disease
## GENERAL:
Sitting on side of bed-admittedly anxious
## SKIN:
Warm [x] Dry [x] intact [x] - well healed sternotomy
## NECK:
Supple [x] Full ROM [x]
## CHEST:
Lungs clear bilaterally [x]
## HEART:
RRR [] Irregular [x] Murmur [x] grade holosystolic
murmur at apex
## ABDOMEN:
Obese, Soft [x] non-distended [x] non-tender [x] bowel
sounds+ [x]
## PERTINENT RESULTS:
TTE
Prebypass
No thrombus/mass is seen in the body of the left atrium. The
left atrial appendage emptying velocity is depressed (<0.2m/s).
No atrial septal defect is seen by 2D or color Doppler. Overall
left ventricular systolic function is moderately depressed
(LVEF= 35 %). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is moderate valvular mitral stenosis (area
1.0-1.5cm2). Mild to moderate ( ) mitral regurgitation is
seen. There is no pericardial effusion. Dr. was
notified in person of the results on at 1115 am
Post bypass:
The patient is a paced and on epinephrine, milronone, and
phenylephrine. A well seated, well functioning mechanical
prosthesis seen in the mitral position. A small perivalvular
leak appreciated. Mean gradient across the new mitral valve is 2
mm Hg. LVEF =30%. RV function within normal limits. Aorta
intact, no aortic dissection appreciated. Rest of the exam
unchanged from before. Surgeon notified about the findings. Poor
echocardiographic windows.
06:15AM BLOOD WBC-6.8 RBC-2.58* Hgb-8.3* Hct-25.3*
MCV-98 MCH-32.3* MCHC-33.0 RDW-15.0 Plt
06:15AM BLOOD
06:15AM BLOOD Glucose-122* UreaN-45* Creat-1.7* Na-133
K-3.3 Cl-88* HCO3-35* AnGap-13
## BRIEF HOSPITAL COURSE:
Mr. was admitted to the hospital and brought to the
operating room on where the patient underwent
redosternotomy, mitral valve replacement #27 mechanical,
MAZE, ligation. Overall he tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found him
extubated, alert and oriented and breathing comfortably. He was
neurologically intact and hemodynamically stable on milrinone,
levo, and Neo. He developed acute kidney injury requiring a
lasix infusion, and diuril. Inotropes and pressors were weaned
off slowly. He developed post-operative atrial fibrillation and
was started on amiodarone and Beta blockers. He was transferred
to the telemetry floor for further recovery. His chest tubes and
pacing wires were discontinued without complication. He
developed bursts of bradycardia n the so lopressor and
amiodarone were held. He was started on coumadin. His
bradycardia improved over the next couple of days. His renal
function was trending towards baseline and he required smaller
doses of lasix in order to diurese adequately. He required
fairly aggressive potassium repletion so his
BUN/Creatinine/potassium should be frequestly checked until his
creatinine normalizes. His intraoperative echo revealed an
ejection fraction of 35% so he should be evaluated for long term
lasix once his renal insufficiency resolves. He was evaluated by
the physical therapy service for assistance with strength and
mobility. By the time of discharge on post-operative day seven
he was was ambulating with assistance, the wound was healing and
pain was controlled with oral analgesics. He was discharged to
in in good condition with
appropriate follow up instructions.
## MEDICATIONS ON ADMISSION:
amlodipine 5 mg daily, clonazepam 1 mg tablet daily, Flonase 50
mcg/actuation nasal spray daily, losartan 100 mg tablet daily,
metoprolol tartrate 25 mg tablet BID (dose increased but he does
not know new dose, Viagra 50 mg tablet prn, warfarin 5 mg tablet
daily, as directed by anticoag clinic
## DISCHARGE MEDICATIONS:
1. ClonazePAM 1 mg PO DAILY
2. Fluticasone Propionate NASAL 1 SPRY NU DAILY
3. Warfarin 5 mg PO ONCE Duration: 1 Dose
Take a daily dose of coumadin per rehab for goal INR of 2.5-3.5
4. Aspirin EC 81 mg PO DAILY
5. Cepastat (Phenol) Lozenge 1 LOZ PO Q2H:PRN sore throat
6. Docusate Sodium 100 mg PO BID
7. OxycoDONE (Immediate Release) mg PO Q4H:PRN pain
RX *oxycodone 5 mg tablet(s) by mouth every four hours Disp
#*40 Tablet Refills:*0
8. Bisacodyl AILY:PRN constipation
9. Furosemide 40 mg PO DAILY Duration: 10 Days
10. Potassium Chloride 20 mEq PO DAILY Duration: 10 Days
## DISCHARGE DIAGNOSIS:
mitral stenosis and regurgitation
atrial fibrillation
## DISCHARGE CONDITION:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
## DISCHARGE INSTRUCTIONS:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns
**Please call cardiac surgery office with any questions or
concerns . Answering service will contact on call
person during off hours**
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "13140001", "visit_id": "23573627", "time": "2145-01-05 00:00:00"} |
10707969-RR-21 | 86 | ## FINDINGS:
The liver echotexture is normal, and there is no focal intrahepatic
lesion or intrahepatic bile duct dilation. The main portal vein is patent,
demonstrating proper hepatopetal flow. The CBD is not dilated, measuring 2
mm. The gallbladder is collapsed (the patient recently ate). No sonographic
sign is elicited. There is no ascites. The pancreas appears normal.
Included views of the right kidney demonstrate an extrarenal pelvis, also seen
on the CT examination.
## IMPRESSION:
Collapsed gallbladder. No intrahepatic bile duct dilation.
Normal liver echotexture.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10707969", "visit_id": "26323055", "time": "2194-12-27 00:25:00"} |
19616286-RR-22 | 265 | ## EXAMINATION:
CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK
## HISTORY:
with tracheal stent 2 weeks ago dysphasia// Tracheal
placement?
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 3.5 s, 27.3 cm; CTDIvol = 15.6 mGy (Body) DLP = 425.1
mGy-cm.
Total DLP (Body) = 425 mGy-cm.
## FINDINGS:
Seen again are multiple enlarged peripherally enhancing cervical lymph nodes
at the 2A/B level. There is adjacent stranding of the adjacent soft tissues
that extends inferiorly down to the chest. The largest on the right measures
2.0 x 2.8 cm, previously 2.5 x 2.6 cm in the largest on the left measuring 3.0
x 3.8 cm, previously 2.7 x 3.7 cm. Multiple other enlarged nodes are seen
along the cervical chain down to the supraclavicular level left greater than
right. The overall appearance of the lymphadenopathy is unchanged since prior
study.
Patient is status post tracheal stenting at the level of the thyroid. Thyroid
remains diffusely enlarged. The stent remains patent and in place. There is
interval increase in retropharyngeal edema seen from levels C2 through 7.
The neck vessels are patent.
The imaged portion of the lung apices are clear and there are no concerning
pulmonary nodules. There are no osseous lesions.
## IMPRESSION:
1. Significantly increased retropharyngeal edema seen from levels C2 through
C7.
2. Tracheal stent is at the level of the thyroid and remains patent.
3. No evidence of new tracheoesophageal masses. Previously seen
lymphadenopathy demonstrates no interval growth.
4. Persistent fat stranding from the mandible extending down to the upper
chest.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19616286", "visit_id": "20101264", "time": "2187-01-22 13:48:00"} |
15863802-DS-43 | 766 | ## HISTORY OF PRESENT ILLNESS:
yo f w/ hx treatment refractory CLL, refractory ascites s/p
Pleurex catheter placed for reaccumulation, presents with
hypotension and lightheadedness. Pt admitted to for
worsening ascites. 5.4 L tapped . Pleurex placed with
1.2 L removed . cc removed. nothing removed.
cc's removed. today 1 L removed. Pt with baseline
BPs high 90's to low 100's systolic. Yesterday started feeling
dizzy. Today, BPs noted to be 70's systolic. Pt thus sent to
ED for eval. Pt denies fever, CP, SOB, change in chronic abd
pain, or any other other complaints. In ED, labs unchanged, CXR
w/o PNA per my read, U/A not sent. Pt had NS hung in ED and
received approx 1 L. BPs now in 90's again. Urine cx and blood
cx not checked in ED.
## PAST MEDICAL HISTORY:
1. CLL. Please refer to OMR note for extensive details.
She is s/p CHOP, CVP, fludarabine-based therapy, Campath,
bendamustine. Most recently she received a cycle of CHOP without
evidence of disease response.
2. Extrapulmonary TB diagnosed , now s/p 6 months of therapy
with rifampin, INH, and moxifloxacin.
3. Hypothyroidism
4. Osteoarthritis
5. Status post ERCP with sphincterotomy for gallstone
pancreatitis and cholangitis, . Status post cholecystectomy
7. History of C. difficile
8. Recurrent ascites
.
## HEENT:
No OP erythema or exudate.
## ABD:
+BS. Pleurex site c/d/i. + ascites. Minimal pain
throughout.
## CXR:
No interval change from prior, without new acute
cardiopulmonary
abnormality. Mediastinal lymphadenopathy and nodular density
projecting over the right inferior hilum are unchanged.
## BRIEF HOSPITAL COURSE:
F w/ treatment refractory CLL and recurrent ascites who p/w
hypotension and dizziness.
.
# Hypotension: Pt. was noted to be in mid systolic at
admission. Given 1L NS in ED, no IVF on floor. BP stabilized at
approx. 90/60 by time of discharge. Asymptomatic throughout on
floor. was consulted and pt. able to ambulate.
.
# Ascites: Pt. had been having 0.8-1L drained from Pleurx
catheter tdaily at home. We removed 1L of fluid on day of
admission and none after that. We instructed the pt. to try not
to remove more than 500-750mL per day of fluid. Fluid showed no
evidence of SBP.
.
# CLL: No treatment wanted at this time.
.
# Anemia: Hct dropped approx. 9 points day of admission. We
attributed to likely hydration. 2 units PRBCs transfused w/o
complication. Hct rose properly.
## MEDICATIONS ON ADMISSION:
1. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO twice a day.
## 4. ALLOPURINOL MG TABLET SIG:
0.5 Tablet PO once a day.
5. Filgrastim 300 mcg/mL Solution Sig: One (1) syringe Injection
QMOWEFR ( ).
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q8H (every 8 hours) as needed for nausea.
9. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a
day.
## DISCHARGE MEDICATIONS:
1. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
4. Filgrastim 300 mcg/mL Solution Sig: One (1) syringe Injection
().
## 5. ALLOPURINOL MG TABLET SIG:
0.5 Tablet PO DAILY (Daily).
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q8H (every 8 hours) as needed for nausea.
9. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a
day.
## PRIMARY:
1. Treatment refractory chronic lymphoid leukemia
2. Recurrent Ascites
## DISCHARGE INSTRUCTIONS:
You were admitted to the hospital with dizziness and low blood
pressure. We think the low blood pressure was caused by removing
too much fluid from your peritoneal catheter. Your blood
pressure rose back to your normal range and you had no more
dizziness. Your blood counts were low and you were transfused
red blood cells.
.
None of your medications were changed during this admission. You
should continue to take all of your medications as previously
prescribed.
.
You should attempt to not remove more than 500-750 milliliters
per day of fluid from your abdomen if possible. You should also
increase the amount of fluids you drink.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15863802", "visit_id": "21070933", "time": "2124-08-02 00:00:00"} |
12936022-RR-29 | 99 | ## INDICATION:
s/p ex fix removal// eval post op
## IMPRESSION:
External fixation hardware has been removed. However, there is an overlying
cast which limits fine bony detail. Hardware is seen along the medial column
with plate and screws within the base of the first metatarsal as well as
within the residual medial cuneiform and navicular. Plate and screws are seen
within the cuboid in calcaneus. There is a screw within the posterior
subtalar joint.The articulation at the TMT joints is poorly visualized and the
base of the metatarsals appear elevated in relation to the midfoot bones.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12936022", "visit_id": "N/A", "time": "2174-06-20 08:58:00"} |
15583964-RR-26 | 129 | ## INDICATION:
A man with marfanoid features presents with
persistent dizziness and headache after chiropractic manipulation.
## FINDINGS:
There is a normal three-vessel takeoff from the aortic arch. The
origins of both common carotid and vertebral arteries are normal. The
cervical portion of the common carotid arteries, internal carotid arteries,
and vertebral arteries are normal, without evidence of dissection, stenosis or
occlusion. There is no evidence for aneurysm formation or other vascular
abnormality. The imaged portion of the intracranial carotid and vertebral
arteries are unremarkable. Incidental note of a fenestration of the basilar
artery.
The imaged lung apices are unremarkable. No osseous abnormality is
identified. Mild mucosal thickening is seen within both maxillary sinuses.
## IMPRESSION:
Normal CTA of the neck, without evidence of carotid or vertebral artery
dissection.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15583964", "visit_id": "N/A", "time": "2172-09-18 10:38:00"} |
16476036-RR-32 | 362 | ## INDICATION:
male with renal cell carcinoma referred for
evaluation of disease status.
## DOSE:
As per CT abdomen/pelvis
## FINDINGS:
The thyroid gland is unremarkable. Multiple nonspecific mildly prominent
mediastinal and bilateral hilar lymph nodes are stable in size and number
since . There is no supraclavicular or axillary lymphadenopathy.
Heart size is top normal with scattered coronary artery and aortic valvular
calcifications. There is no pericardial effusion. Chronic pulmonary emboli
involving the right main pulmonary artery with extension into right middle and
lower lobe segmental branches are minimally improved. Left upper lobe
pulmonary artery thrombus is also unchanged. There are no new areas of central
pulmonary arterial occlusion. There is new mild dilatation of the main
pulmonary artery to 3.2 cm. The thoracic aorta is normal caliber.
Numerous pre-existing pulmonary metastases are not significantly changed in
size and number since . For reference, the largest right apical
metastasis is stable measuring 9 mm (6, 56). A medial right lower lobe
subpleural metastasis is stable measuring 5 mm (6, 159). A left upper lobe
nodule is also stable measuring 7 mm (6, 91). There are new ground-glass
opacities in the bilateral upper lobes. Subsegmental ground-glass opacities
have increased in the right middle lobe. There is no endobronchial or pleural
abnormality.
The patient is status post left nephrectomy. For a more detailed discussion of
the upper abdomen, including numerous hepatic metastases, please refer to the
separate report from the CT abdomen/ pelvis performed concurrently.
Lytic lesions involving the T12 through L3 vertebral bodies are unchanged.
## IMPRESSION:
No significant interval change in pre-existing pulmonary metastases as
described above.
Interval worsening of right middle lobe subsegmental ground-glass opacities
with new bilateral upper lobe ground-glass opacities, which are likely due to
superimposed hemorrhage, less likely infection.
Unchanged thrombus burden involving the right main pulmonary artery, right
middle and lower lobe segmental branches, and left upper lobe pulmonary
artery. New dilatation of the main pulmonary artery suggests developing
pulmonary hypertension.
Stable mature bony metastases involving T12 through L3.
## NOTIFICATION:
The findings were discussed by Dr. with Dr. on the
telephone on at 3:13 , 60 minutes after discovery of the findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16476036", "visit_id": "N/A", "time": "2123-11-26 08:53:00"} |
16560392-DS-12 | 2,125 | ## ALLERGIES:
Penicillins / nuts / berries / dairy
## CHIEF COMPLAINT:
Chest Pain, Polyarthralgias, Myalgias
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Bone Marrow Biopsy ( )
Right Tibial Biopsy ( )
## HISTORY OF PRESENT ILLNESS:
Mr. is a year old male with limited PMH of
significant animal/food/environmental allergies and hx. of back
pain who presents with chest pain in the setting of a 3 month
course of extensive myalgias, arthralgias, joint swelling, and
worsening lower back pain.
To describe pt's episode of chest pain, pt. awoke in the AM of
presentation and maneuvered himself to a semi-standing position
with his crutches when he noted the onset of acute
substernal/left-sided heavy chest pain. Pt. denies feeling a
similar sensation to this pain in the past. He has continued to
have chest pain consistently from the early AM to the time of
this interview. He denies any significant dyspnea on exertion,
orthopnea, or classic PND symptoms (although he notes that he
wakes up suddenly at night with acute pain). His movement is
restricted to approximately 25 feet at this time as he becomes
extremely weak to intense pain. Prior to 3 months ago, pt.
was very active, walking long distances without issue. He
denies any previous episodes of anginal type chest pain.
To describe the pt's history of musculoskeletal symptoms, pt.
notes injuring his back after heavy lifting 6 months prior to
presentation. At that time, pt. was treated with flexiril, ,
and chiropracter visits with improvement back to baseline. Pt.
had several months of normal health until a maxillary molar
extraction on . Pt. notes developing a dry socket that
was treated with water irrigation. He denies any surgical
implant or closure in this area. He did however develop
significant pain from the dry socket. TO control his pain, he
took a long course of ibuprofen/tylenol Q6H for
approximately 20 days. Approximately 10 days into this period
of time, pt. noted reinjury of lower back pain after doing some
moderate lifting. Pain localized to the same lower back
location as noted before, however on this occassion, the pain
was severe with radiation and numbness extending down both egs.
An MRI at this time revealed L2-L3 disc bulge.
For ongoing back pain, pt. presented to a pain specalist who
performed 2 single injection cortisone shots in his lower back.
His back pain persisted localized in the SI joints bilaterally.
Some time after these injections, he noted the onset of acute
bilateral knee swelling with subsequent ankle and toe swelling
bilaterally (pt. notes his shoes are no longer fitting). Later
he noted bilateral wrist swelling and swelling of all three
joints of his hands but most notably the MCP joints. He also
describes diffuse waxing and wanning sharp calf pain, less so in
thighs. He does note bilateral muscular shoulder and upper back
pain as well. He denies any involvement of the hips, elbows,
and only minimal involvement of the neck at this time.
In this setting, pt. endorses a 1 month history of brief
minutes episodes of diffuse whole body sweats, diffuse headache,
and nausea type symptoms. He denies lightheadedness, dizziness,
or vomiting associated with these episodes. He denies any
recent travel over the last many years. His place of work is on
a Farm in , where there are many different types of
animals. Because of his allergy history, he does not have much
in the way of direct contact with these animals. Otherwise, no
animals at home. Denies any rashes or tick bites that he noted
over the summer.
Pt. has had multiple ED visits. He was placed initially on a 5
day course of prednisone 10mg, minimal response and therefore
later increased to 20mg for 5 days. For ongoing symptoms, he
was admitted to from where a
rheumatologic, infectious disease, and neurosurgical evaluation
took place. There was concern for subacute bacterial
endocarditis so TTE was done which showed LVEF 55% with normal
global/regional systolic function. BCx negative x4 sets. Rheum
eval was only notable for mild elevation in calcium and ESR,
otherwise unremarkable. He was started on a course of
prednisone 60mg PO Daily on . He notes no improvement
on this regimen. For persistent symptoms, pt. discussed with
his PCP that he present to the ED.
## IN THE ED, INITIAL VITALS:
T:97.0 HR:88 BP:142/94 16 100% RA
Exam in the ED notable for reproducible chest pain. Troponins
returned negative x2, labs otherwise unremarkable. EKG showed
SR, normal axis, with non-specific t-wave flattening in inferior
leads. Serial EKGs unchanged, no other concerning ischemic
changes noted. Pt. received home dose of prednisone, oxycodone,
pantoprazole, aspirin, morphine, and nitro. Pt. was admitted
for further rule-out, evaluation of polyarthritis, and work-up
for hypercalcemia.
## ROS:
Denies any changes in vision, temporally located
headaches, dysuria, significant changes in voiding habits. Does
note some constipation and dry mouth that he attributes to his
narcotic use.
## PAST MEDICAL HISTORY:
Polyarthritis of unknown etiology (work-up ongoing)
Vitamin D Deficiency
Hx. of infrequent back pain (prior to illness)
## FAMILY HISTORY:
Mother with history of CHF, HTN, DM, CKD, and rheumatoid
arthritis vs. OA. 2 sisters with breast CA (both live in ,
1 deceased, other diagnosed at age , unclear BRCA status).
Otherwise, no signficant, autoimmune or rheumatologic illnesses
he is aware of.
## ADMISSION PHYSICAL EXAM:
====================
Vitals- 99.1, 133/84, 85, 18, 97% on RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, Dry MM, oropharynx clear
Neck- supple, limited range of movement by pain, otherwise JVP
not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
Ext- Pt. with tenderness of the bilateral knees mostly on the
medial surface, tenderness to palpation of the posterior calf,
1+ pitting edema of the bilateral ankles extending to the
dorsum of the foot to the toes. Possibly some mild swelling of
bilateral hands at the MCP and PIP, no swelling noted at the
DIP. No notable erythematous or warm joints on exam. Moderate
tenderness to the bilateral SI points. Otherwise, warm/well
perfused, 2+ pulses, no clubbing, cyanosis or edema
## DISCHARGE PHYSICAL EXAM:
===================
VSS
Exam unchanged
## IMPRESSION:
1. No evidence of abdominal or pelvic malignancy.
2. Please see a separate report discussing findings within the
thorax.
## CT CHEST ( ):
No definite evidence for intrathoracic
malignancy. Old right posterolateral
sixth rib fracture with irregular margins and lucency may
reflect a pathologic
fracture from metastatic disease or prior fracture with
complications.
## FOOT XRAY ( ):
Very extensive aggressive lytic
multifocal lesions throughout the visualized
feet an also involving bilateral distal tibia and left fibula.
Differential diagnosis includes metastasis, myeloma however
given the relative paucity of lesions identified in the recent
torso CT, the distribution is atypical. Alternative
considerations including unusual infections or tuberculosis
should be considered.
## HAND XRAY ( ):
Multiple lytic lesions within the bones
of both hands and wrist with a
probable pathologic fracture involving the left second
metacarpal concerning for metastasis, multiple myeloma or an
atypical infection. Clinical correlation is advised.
## KNEE ( ):
Multiple lytic lesions involving both knees.
The differential includes metastasis, multiple myeloma, or
atypical infection. Clinical correlation is advised.
## SKELETAL SURVEY ( ):
Nonspecific circumscribed lucencies
within the bilateral femoral necks may correspond to myelomatous
lesions. Further evaluation with MRI can be obtained
if clinically indicated.
## BRIEF SUMMARY STATEMENT:
Mr. is a year old male
with limited PMH of significant animal/food/environmental
allergies who presents with chest pain in the setting of a 3
month course of subjective fevers, body sweats, extensive
myalgias, polyarthralgias, joint swelling, and worsening lower
back pain. Pt. found to have unconcerning EKG and negative
cardiac enzymes. Given pt's initial symptoms, rheumatology was
consulted whose work-up was unrevealing. Further work-up
revealed multiple lytic lesions bilaterally and diffusely.
Heme/Onc and ID were both consulted. Multiple cultures, bone
marrow biopsy and right tibial bone biopsy pending at discharge.
ACTIVE ISSUES
==============
## # CHEST PAIN:
Pt. presented with several hour long history of
chest pain. Cardiac enzymes returned negative. EKG not
suggestive of ischemia. Pt's chest pain was not thought to be
cardiac and was more likely thought to be musculoskeletal likely
related to ongoing symptoms of polyarthralgias/myalgias.
## # MULTIPLE LYTIC LESIONS:
Pt. presented with several month
history of myalgias and arthralgias. Initially, pt's symptoms
were thought to be some type of symmetric polyarthropathy. As
such, rheumatology was consulted. Rheum work-up was grossly
negative. CT Torso was performed with evidence of right rib
fracture, no hx. of trauma per pt. Given localized feet
swelling and pain, foot X-rays were done which revealed
extensive aggressive lytic lesions in bilateral feet. Given
these findings, Heme Onc was consulted for possible evaluation
of malignancy. Multiple myeloma was initially suspected based
on history of symptoms, intermittent hypercalcemia, and newly
diagnosed lytic lesions. Bone marrow biopsy was done without
clear evidence of malignant process. As such, ID was consulted
for possible atypical infection causing these lytic lesions. ID
and Heme Onc both recommend biopsy of a lytic lesion. Biopsy
was done, results pending at discharge. Pt's pain was under
control at time of discharge home. He was set up to see ID,
Rheum, and Heme/Onc as an outpatient pending biopsy results.
## # HYPERCALCEMIA:
Pt. presented with hx. of hypercalcemia with
extensive negative work-up at OSH. Given lytic findings on
X-rays, his hypercalcemia is likely related to lytic bone
process.
## CHRONIC ISSUES
===============
# MULTIPLE ALLERGIES:
Pt. with hx. of multiple allergies with
ongoing allergy desensitization. He was continue on cetirizine
and recommended to hold off on additional allergy treatments at
this time.
## # CONSTIPATION:
Likely related to ongoing narcotic use. Pt.
discharged on increased bowel regimen.
## TRANSITIONAL ISSUES
=====================
# BONE MARROW BIOPSY:
Pt. needs follow-up of bone marrow biopsy
studies sent on this admission.
# Tibial Biopsy: Pt. needs follow-up of tibial biopsy taken on
this
admission.
# Multiple blood and bone cultures: Require follow-up.
#Allergy Desensitization: Would recommend holding off on further
allergy desensitization treatments until results of biopsy
return.
# CODE STATUS: Full Confirmed
# CONTACT: wife,
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 60 mg PO DAILY
2. Vitamin D 50,000 UNIT PO 1X/WEEK (SA)
3. Pantoprazole 40 mg PO Q24H
4. Senna 17.2 mg PO BID
5. Cetirizine 10 mg PO DAILY
6. OxycoDONE (Immediate Release) 15 mg PO TID
7. Voltaren (diclofenac sodium) 1 % topical BID:PRN Sore Joints
## DISCHARGE MEDICATIONS:
1. Cetirizine 10 mg PO DAILY
2. Pantoprazole 40 mg PO Q24H
3. Senna 17.2 mg PO BID
4. Voltaren (diclofenac sodium) 1 % topical BID:PRN Sore Joints
5. Acetaminophen 650 mg PO QID
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*90 Tablet Refills:*2
6. Docusate Sodium 200 mg PO BID
RX *docusate sodium 100 mg capsule(s) by mouth twice a day
Disp #*120 Capsule Refills:*2
7. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN Pain
RX *oxycodone 5 mg tablet(s) by mouth every six (6) hours
Disp #*180 Tablet Refills:*0
8. OxyCODONE SR (OxyconTIN) 10 mg PO QPM
RX *oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth In the
evening Disp #*30 Tablet Refills:*0
9. Polyethylene Glycol 17 g PO DAILY
Hold if you are having frequent loose stools.
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth Daily
Disp #*30 Packet Refills:*3
10. TraMADOL (Ultram) 50 mg PO Q8H:PRN Pain
RX *tramadol 50 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
11. Commode
Please distribute 1x Commode
## DX:
Other specific muscle disorders
## ICD-9:
728.3
12. Shower Chair
Please distribute 1x Shower Chair
## DX:
Other specific muscle disorders
## DISCHARGE DIAGNOSIS:
PRIMARY DIAGNOSES
===================
Lytic Bone Lesions of Unknown Etiology
Non-Cardiac Chest Pain
SECONDARY DIAGNOSES
======================
Various Environmental, Animal, and Food Allergies
## DISCHARGE INSTRUCTIONS:
Mr. ,
It was a pleasure caring for you during your hospitalization at
. You were admitted with chest pain and diffuse body pains
that have been ongoing for several months. Your chest pain was
likely do to a musculoskeletal injury as our cardiac testing
returned negative. Your body pain work-up revealed concerning
bones lesions in many places but predominanty in the hands,
wrists, knees, and feet. We consulted rheumatology,
hematology/oncology, and the infectious disease doctors to help
with your case. You had a bone marrow biopsy and biopsy of
your leg bone (the tibia). The results of these biopsies
continue to be pending at this time. You should follow-up as an
outpatient with the hematologists and the infectious disease
doctors.
Again, it was a pleasure to meet you. We wish you a speedy
recovery.
All the best,
Your Care Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16560392", "visit_id": "22930324", "time": "2144-10-22 00:00:00"} |
11410076-RR-27 | 153 | ## HISTORY:
male with recent traumatic intracranial hemorrhage
status post surgical evacuation and left frontoparietal craniectomy.
## FINDINGS:
The post-surgical changes from the prior craniectomy are again
seen, with decreasing pneumocephalus. There is no significant change in the
multifocal subarachnoid hemorrhage. Blood remains present in the occipital
horns of the lateral ventricles, which are stable in size. The subarachnoid
hemorrhage in the right limb of the quadrigeminal plate cistern is slightly
less dense, consistent with the expected evolution of blood products. No new
hemorrhage is identified. There is no shift of midline structures, evidence of
herniation or evidence of a new large infarction.
Underlying parenchymal atrophy is unchanged. There is a chronic lacunar
infarction in the left caudate and a hypodensity in the right frontal lobe,
also likely related to a chronic infarct. The right mastoid air cells are
partially opacified. The paranasal sinuses, however, are clear.
## IMPRESSION:
No significant interval change.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11410076", "visit_id": "29714083", "time": "2154-08-16 10:36:00"} |
18634238-RR-7 | 110 | ## INDICATION:
History of IVH, intubated with fevers, assess for interval
change.
## FINDINGS:
Endotracheal tube ends 7.2 cm from the carina. Nasogastric tube
passes into the stomach and out of view. Increased opacity at the right base
appears to be an unusual configuration of right middle lobe atelectasis.
Retrocardiac opacity reflects atelectasis. Cardiomegaly is stable normal
cardiomediastinal silhouette. No pleural effusions or pneumothorax seen.
## IMPRESSION:
1. Right middle lobe and left base atelectasis.
2. Endotracheal tube is 7.2 cm from the carina, recommend to advance by 3 cm.
3. Recommend advancing nasogastric tube 4-5 cm.
These findings were relayed by Dr. to Dr. at 1051 on .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "18634238", "visit_id": "22722473", "time": "2123-04-05 03:54:00"} |
19329862-DS-21 | 2,141 | ## HISTORY OF PRESENT ILLNESS:
Ms. is a lady with PMH of sickle cell anemia and
rheumatoid arthritis, admitted with malaise and cough for 5 days
concerning for acute chest syndrome.
She reports that of this week she began to feel
fatigued, generally unwell. Over the next several days, she
developed a cough productive of yellow sputum and dyspnea on
exertion. She also complains of a sharp pleuritic pain with deep
inspiration as well as several days of sore throat. The pain is
primarily right-sided on her chest.
She went to today and had an Xray there with
concern for focal infiltrate and R pleural effusion. She was
sent
over to the ED. In the ED she had no chest pain, but
reported continued dyspnea.
ED COURSE
## - EXAM:
notable for crackles and decreased breath sounds on the
right midlung and base. No abdominal pain. Positive scleral
icterus, mild. Satting 87%RA
- Labs: WBC 12, H/H 5.6/16.4 (runs more like , Cr 18,
Tbili 21.7, Dbili 14, CRP 18, Lactate 0.8.
- Imaging: CXR PA/Lat - new R lung consolidation. Additional
pleural opacity, possibly thickening v. parenchymal opacity.
Cardiomegaly and mild pulmonary edema
- Consults: none
- Interventions: Got IVF, CEFTRI 2gm, LEVAQUIN 750mg, 1U pRBC,
second unit hanging as she was transferred
Upon arrival to the floor, Mrs. reports improvement in
chest pain, but continued DoE and mild pleuritic right-sided
chest pain. She also reports HA which has been present for the
past 3 days. It is bilateral, frontal, pressure-like in
character. No vision changes, dizziness, confusion, slurred
speech, word-finding difficulties.
Regarding pain control, she reports that at home she usually
uses
dilaudid once daily and the morphine long-release 3 times
weekly.
She has not required hospitalization for her sickle cell in
years.
In on hydroxyurea 500mg daily for hematocrit in high teens.
Transfused blood before hip was replaced.
Of note, she is at baseline on 3LNC oxygen at home, though she
reports that she often will only use it at night.
## PAST MEDICAL HISTORY:
- Sickle Cell Disease
- Rheumatoid Arthritis, started ertanercept
- Diastolic CHF
- THA
- Paroxysmal SVT
- Pulmonary HTN, s/p cardiac cath in
- Mitral Stenosis, mild
## FAMILY HISTORY:
Brother Cancer
Father at CAD/PVD
Mother at Onset; Hypertension
## GEN:
Well-appearing lady in no acute distress
## EYES:
Sclerae icteric. PERRL. EOMI.
## ENT:
Sublingual and palatal jaundice present.
## CV:
Tachycardic, regular rhythm. Nl S1, S2. No m/r/g.
## RESP:
Crackles throughout. BS decreased.
## NEURO:
AOx3. Moving all 4 extremities with purpose.
## GEN:
Well-appearing lady, seated comfortably in bed.
## EYES:
Sclerae anicteric, significantly improved. PERRL. EOMI.
## CV:
Irregularly irregular rhythm. Nl S1, S2. No m/r/g.
## RESP:
BS still decreased throughout, but improved. No rales,
wheezes, or rhonchi.
## NEURO:
AOx3. Moving all 4 extremities with purpose.
## PERTINENT RESULTS:
ADMISSION LABS
09:00PM BLOOD WBC-13.3*# RBC-1.85*# Hgb-5.4*#
Hct-16.4*# MCV-89 MCH-29.2 MCHC-32.9 RDW-20.2* RDWSD-57.4* Plt
09:00PM BLOOD Neuts-62.9 Monos-8.5 Eos-2.1
Baso-0.2 NRBC-4.4* Im AbsNeut-8.32*# AbsLymp-3.25
AbsMono-1.13* AbsEos-0.28 AbsBaso-0.03
09:00PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-2+*
Macrocy-2+* Microcy-NORMAL Polychr-1+* Ovalocy-OCCASIONAL
Target-1+* Schisto-OCCASIONAL Tear Dr-OCCASIONAL
09:00PM BLOOD PTT-26.9
09:00PM BLOOD Plt Smr-NORMAL Plt
09:00PM BLOOD Ret Man-15.0* Abs Ret-0.28*
09:00PM BLOOD Glucose-94 UreaN-45* Creat-1.5* Na-141
K-5.0 Cl-102 HCO3-21* AnGap-18*
09:00PM BLOOD ALT-11 AST-21 LD(LDH)-404* AlkPhos-73
TotBili-20.0* DirBili-15.9* IndBili-4.1
09:00PM BLOOD Albumin-3.8 Calcium-9.1 Phos-2.9 Mg-2.5
09:15PM BLOOD pO2-74* pCO2-40 pH-7.38
calTCO2-25 Base XS-0
IMPORTANT LABS
06:15AM BLOOD HCV Ab-NEG
06:15AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG IgM HAV-NEG
:34AM BLOOD TSH-2.4
10:30AM BLOOD Hapto-39
06:15AM BLOOD calTIBC-157* Ferritn-882* TRF-121*
06:15AM BLOOD cTropnT-<0.01
02:25PM BLOOD cTropnT-<0.01
09:59PM BLOOD cTropnT-<0.01
DISCHARGE LABS
06:29AM BLOOD WBC-6.2 RBC-3.73* Hgb-11.2 Hct-33.5*
MCV-90 MCH-30.0 MCHC-33.4 RDW-18.3* RDWSD-59.0* Plt
06:29AM BLOOD Plt
06:29AM BLOOD Glucose-75 UreaN-8 Creat-0.7 Na-140 K-4.3
Cl-104 HCO3-21* AnGap-15
06:34AM BLOOD ALT-11 AST-21 LD(LDH)-306* AlkPhos-69
TotBili-7.5*
06:29AM BLOOD Mg-2.1
RADIOLOGY
CXR
New right lung parenchymal opacities which could represent
pneumonia.
Additional pleural based opacity, potentially pleural thickening
or additional
region of parenchymal opacity. Cardiomegaly and mild pulmonary
edema.
Suggest follow-up after treatment.
CARDIOLOGY
ETT
Poor exercise tolerance. No anginal symptoms or ischemic ST
segment changes. Sinus vs atrial/junctional tachycardia noted
during the
procedure. No exercise-induced heart block. Appropriate
hemodynamic
response to exercise.
The left atrial volume index is severely increased. The
estimated right atrial pressure is mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). 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. There is mild
functional mitral stenosis (mean gradient mmHg) due to
diastolic restriction of the posterior mitral leaflet. Trivial
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
## IMPRESSION:
Thickened/restricted posterior mitral leaflet with
mild functional mitral stenosis (?rheumatic, calcium deposition,
lupus, etc). Normal global and regional biventricular systolic
function. Marked left atrial enlargement.
## BRIEF HOSPITAL COURSE:
===============
PATIENT SUMMARY
===============
Ms. is a year-old female with PMH of sickle cell
anemia, rheumatoid arthritis, and diastolic CHF presenting with
chest pain, cough, and lung consolidation c/f acute chest
syndrome, with subsequent development of atrial fibrillation.
============
ACUTE ISSUES
============
# Acute Chest Syndrome
# Sickle Cell Disease
Symptoms and CXR c/w ACS in the setting of known sickle cell
disease, Hb 5.4 on admission. Treated with a total 5 day course
of Ceftriaxone to Cefpodoxime/Azithromycin. Prophylaxed with
Lovenox. Transfused to goal of Hb near 10, Hb 11.2 at time of
discharge. Switched from Dilaudid to Oxycodone to minimize nodal
blockade. Patient discharged on daily folic acid
supplementation.
# Atrial Fibrillation
New irregular heart beat , initially bradycardic. Initial
EKGs with ectopic atrial focus, some concern for mobitz I/II,
cards consulted. TSH nl, lyme serologies negative,
and posterior leaflet MV thickening. No evidence of
iron overload based on iron studies. Subsequently, patient was
mostly in a fib with intermittent 2:1 flutter and 1:1 flutter.
Trops NEG. All asymptomatic and HD stable. ETT w 1:1 AV
conduction at max HR of 107. Patient was started on Apixaban 5mg
BID, all nodal blockers avoided (she had been on atenolol as an
outpatient). Cardiology was consulted, recommended continuation
of anticoagulation and further assessment as o/p, no emergent
indication for pacemaker. Given conduction disease, atrial
enlargement, mitral thickening, cholestasis, prior pulmonary
nodules, and previous h/o rheumatologic diagnosis we discussed
whether sarcoidosis could be a unifying diagnosis. Recommend
continued follow-up as outpatient.
# CHF
No clear pulmonary edema or effusion on CXR at time of
admission, and no edema. showed normal LVEF, normal
biventricular systolic function. Lasix held throughout admission
and at time of discharge, should be restarted as outpatient as
needed, no evidence of volume overload.
# Direct Hyperbilirubinemia, resolved
No abdominal pain or nausea/vomiting. Would expect an indirect
hyperbilirubinemia with active hemolysis iso of sickle crisis
but not such a significant direct hyperbilirubinemia. Small
bilirubin in urine also c/w direct process. Suspect obstructive
hepatopathy iso SCD, which has been described in the literature.
RUQUS unremarkable. Hepatitis studies NEG (patient though with
non-immunized HepB status) and no signs of iron overload.
consider granulomatous hepatic involvement sarcoidosis as
above given concomitant conduction disease and prior pulmonary
nodules. Tbili trended downward (>20 -> ~7) and icterus
improved.
==============
CHRONIC ISSUES
==============
# Rheumatoid Arthritis, controlled
Held Etanercept given acute infection, ok to restart as
outpatient.
# Essential HTN
BPs stable here. Held atenolol, esp I/s/o possible heart block.
Will continue holding atenolol.
===================
TRANSITIONAL ISSUES
===================
[ ] Hb 11.2 at time of discharge
[ ] Given AV nodal disease, should avoid nodal blockers, have
switched hydromorphone -> oxycodone to decrease nodal
suppression as per cardiology recommendations
[ ] Given mitral thickening/tethering and AV conduction
disease/atrial tachyarrhythmias in a patient w prior
rheumatologic disease and prior pulmonary nodules, possible
concern for sarcoidosis as unifying diagnosis. Consider further
w/u as an outpatient
[ ] Started on Apixaban for new consider as
outpatient, patient is currently asymptomatic
[ ] Home Lasix 40mg held throughout admission, not restarted at
time of discharge, continue to monitor volume status as an
outpatient
[ ] Atenolol held in setting of possible heart block. Cards to
f/u and assess whether appropriate to restart
[ ] Etanercept held during admission given acute infection, to
be restarted as an outpatient, patient has rheumatology f/u
scheduled
[ ] Needs HBV vaccination, labs obtained show non-immune status
[ ] Ensure that patient is up to date on all vaccines given
likely autosplenectomy status iso SCD
[ ] Patient given 1wk supply of oxycodone 10mg (40 pills),
checked, patient filled 30 day supply of MS
, 16 day supply of Hydromorphone patient
instructed to dispose of recently filled
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Morphine SR (MS 60 mg PO Q12H
2. HYDROmorphone (Dilaudid) 4 mg PO Q4H:PRN Pain - Severe
3. Zolpidem Tartrate 10 mg PO QHS
4. etanercept 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK
5. Aranesp (in polysorbate) (darbepoetin alfa in polysorbat) 100
mcg/0.5 mL injection 1X/WEEK
6. Mirtazapine 15 mg PO QHS
7. Potassium Chloride 20 mEq PO DAILY
8. Atenolol 12.5 mg PO DAILY
9. Furosemide 40 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice daily
Disp #*30 Tablet
## REFILLS:
*1
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
3. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 10 mg 1 tablet(s) by mouth every 4 hours as needed
Disp #*40 Tablet Refills:*0
4. Aranesp (in polysorbate) (darbepoetin alfa in )
100 mcg/0.5 mL injection 1X/WEEK
5. etanercept 50 mg/mL (0.98 mL) subcutaneous 1X/WEEK
6. Mirtazapine 15 mg PO QHS
7. Morphine SR (MS 60 mg PO Q12H
8. Zolpidem Tartrate 10 mg PO QHS
9. HELD- Atenolol 12.5 mg PO DAILY This medication was held. Do
not restart Atenolol until your cardiologist instructs to do
so
10. HELD- Furosemide 40 mg PO DAILY This medication was held.
Do not restart Furosemide until your PCP instructs to do so
11. HELD- Potassium Chloride 20 mEq PO DAILY This medication
was held. Do not restart Potassium Chloride until are told
to do so by your doctor
## PRIMARY:
- Acute chest syndrome
- Pneumonia
- Atrial fibrillation
- Mobitz I Heart Block
- Direct Hyperbilirubinemia
## SECONDARY:
- Diastolic Heart Failure
- Rheumatoid Arthritis
- Essential Hypertension
## DISCHARGE INSTRUCTIONS:
Dear ,
were admitted to the hospital for pneumonia concerning for
acute chest syndrome (a complication of sickle cell disease). We
gave intravenous antibiotics and switched those over to oral
antibiotics to complete a 5 day course. Your breathing improved
significantly.
While were here, also developed some abnormal
heartbeats. We had the cardiology team see and they agreed
that had what we call atrial fibrillation, which is when
your heart is beating irregularly. did not have any symptoms
from it (for example, lightheadedness or dizziness). also
had a few times where your heart was beating slowly, but it was
also not symptomatic. At this time, they did not feel needed
a pacemaker, but that may be an issue to discuss in the future
if develop new symptoms. At this point, the only thing we
need to do is continue on the blood thinner we started
(Apixaban), which has been called in to your pharmacy.
When get home, will need to continue taking the Apixaban
twice daily. will also need to follow up with your
hematologist, PCP, .
should not be taking hydromorphone (dilaudid) for pain
control, as this can slow your heart rate down last filled
a prescription on . can return the hydromorphone
have at home to the pharmacy for disposal. should
instead take oxycodone as needed.
It was a pleasure taking care of !
Sincerely,
Your medical team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19329862", "visit_id": "27985513", "time": "2132-09-08 00:00:00"} |
19897135-RR-65 | 227 | ## INDICATION:
woman with left lower quadrant pain and history of
right ovarian torsion and prior hemorrhagic ovarian cyst.
## LMP:
.
Transabdominal and transvaginal examinations were performed, the latter to
better evaluate the ovary and endometrium.
The uterus is anteverted and demonstrates an anterior scar due to prior C-
section. It measures 6.9 x 4.7 x 4.1 cm. There are no focal masses or
fibroids. The endometrium is normal, measuring approximately 15 mm, and
contains a small amount of physiologic fluid in the endometrial cavity.
The right adnexa is unremarkable, and the patient is post-right oophorectomy.
The left ovary measures 6 x 5.6 x 5.6 cm and contains a large cystic structure
with complex internal echoes, measuring 5.2 x 3.5 x 5.3 cm. This is most
suggestive of a hemorrhagic ovarian cyst, although a less likely consideration
includes endometrioma. Normal flow and Doppler waveforms are demonstrated in
the ovarian stroma surrounding the cyst.
There is no free fluid in the pelvis and no hydronephrosis.
## IMPRESSION:
1. 5.3 x 5.2 x 3.5 cm left ovarian cyst, most likely hemorrhagic. No
intrapelvic free fluid. Ultrasound followup is recommended in six weeks.
2. No ultrasound evidence of torsion. Normal flow and waveforms demonstrated
in the left ovary. Ultrasound cannot exclude transient torsion.
3. Normal uterus without focal lesion.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19897135", "visit_id": "N/A", "time": "2114-08-10 15:18:00"} |
14344003-DS-12 | 1,771 | ## HISTORY OF PRESENT ILLNESS:
Ms. is an year-old
female with a history of HTN, HL, CHF, afib on coumadin,
hypothyroidism, dementia who presented from home after an
unwitnessed fall. She is a poor historian and cannot give much
detail about the event but believes she was walking in her
kitchen when she fell and hit her head. She does not recall
losing consciousness. She reports feeling in her usual state of
health up until the event and does not recall having chest pain,
palpitations, nausea, lightheadedness, or diaphoresis prior to
the fall. She denies any confusion on waking or bladder or bowel
incontinence. Per her daughter, she has had frequent falls. Pt
does admit to gradually increasing leg weakness due to "old
age."
She reports several recent falls. She should use a walker at
home but does not always do so. Her husband 'yells' at her for
this. It takes her a while to get up from bed and she feels
weaker and less mobile than previously.
On this occasion she was going to the bathrooom. Prior to
using the toilet she fell and struck her head on the toilet
bowl. Her hip is also hurt (right). She did not feel lightheaded
or loose consciuosness.
In the ED, initial VS were: T 97.8. P 98 irreg, BP 130/91, O2sat
97 RA. Pt's exam was notable for head abrasians. CT head and C
spine were negative. She was in afib but became tachycardic to
130s although remained asymptomatic; she was given diltiazem
10mg IV x 2, followed by diltiazem 60mg po. She was also given
ASA 325mg, a Td injection, and tylenol 1gm po for pain. On
transfer, VS were P , BP 160/101, O2sat 96% RA.
.
On the floor, pt currently is without complaints other than a
sore head s/p fall. She otherwise feels at baseline.
.
Review of systems:
Denies fever, chills, night sweats, recent weight loss or gain.
Denies sinus tenderness, rhinorrhea or congestion. Denies cough,
shortness of breath. Denies chest pain or tightness,
palpitations, or decrease in exercise tolerance. Denies nausea,
vomiting, diarrhea, constipation or abdominal pain. No recent
change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. All other systems negative.
## PAST MEDICAL HISTORY:
HTN
hypercholesterol
afib
cognitive dysfunction
hypothyroid
chronic leg pain
h/o c diff
congestive heart failure
## GEN:
Patient lying asleep in bed. Awoke with loud voice to full
alertness. Appears stated age. Normal weight range.
## NECK:
Reasonably supple, no JVD, no LAD.
## CARDIOVASCULAR:
Irregular, normal s1 s2, no M/R/G.
## RESPIRATORY:
Clear throughout with suboptimal respiratory
efforts.
## GASTROINTESTINAL:
Benign - non-tender, no rebound, guarding.
Bowel sounds present. No organomegaly.
## EXTREMITIES:
Venous and arterial insufficiency lower
extremities, no cyanosis, no edema.
## NEUROLOGICAL:
Oriented to self and place, but not year, month,
date. Is oriented to context of admission and problem with
recent falls. Bradykinetic. Slow resting tremor. Slight masking
of facies. EOM with delayed fractured horizontal pursuit, but
with intact vertical gaze. No nystagmus. Cranial nerves
otherwise intact. Muscle bulk approriate to age. Tone increased
in limbs with cogwheeling. Axial tone less increased than in
extremities. Power full throughout. Reflexes deferred.
Coordinated movements very slow. Gait stooped, shuffling,
turning on numbers. Very unsteady. Did not report
lightheadedness at time of walking her (but found her to be -
see above).
## SKIN:
Bruises on head and right hip
Pressure ulcer(s): None.
## IMPRESSION:
1. No evidence of fracture within the cervical spine.
2. Mild to moderate multilevel spondylosis resulting in mild to
moderate spinal canal stenosis. If clinical suspicion is high
for cord or ligamentous injury, MRI can be performed if not
contraindicated.
3. Minimal anterolisthesis of C5 on C6.
CT HEAD at admission and later in stay:
## IMPRESSION:
1. No intracranial hemorrhage or large vascular territorial
infarct.
2. Unchanged age-related involutional change and small vessel
ischemic disease.
3. Partial opacification of the mastoid air cells bilaterally,
likely due to inflammatory process.
## IMPRESSION:
No acute intracranial hemorrhage. Chronic small
vessel ischemic changes and age-related involutional change is
similar in appearance.
CXR
## IMPRESSION:
Minimal basilar predominant interstitial opacities,
which may be due to minimal interstitial edema considering
fluctuating course on serial chest radiographs. An acute viral
or mycoplasma pneumonia is also possible in the appropriate
clinical setting.
## BRIEF HOSPITAL COURSE:
Precis
This year old woman has Parkinsonism and orthostatic
hypotension, with a likely mechanical fall, based on her
history. Orthostasis still has to be considered as a cause,
given the disparity between this history and the admission
history. It is possible that her orthostasis has resulted from
her cerebrovascular/neurodegenerative disease, but it has
improved markedly with a medication change and rehydration. She
appeared to be living in poor conditions - near squalor - at
home, and likely had poor PO intake. Gait instability is
dramatic and now hypoactive delerium. Psychotropic medications
were stopped with improvement. She will need rehabilitation and
re-evaluation for the level of care that she requires.
Fall
Etiologies include arrhythmia, simple mechanical, orthostatic,
vagal and mechanical in context of movement disorder. Given
physical exam, Disease is the likely cause of her
Parkinsonism given normal vertical eye movements and no
cerebellar signs, rigidity of extremities. Possible, indirect
contribution by UTI. Hit head and right hip. Head CT clear in ED
and then later. She fell again on the floor, but her fall was
broken and she did not strike her head again. This was prior to
her second head CT. Hip x-ray was clear. Sinemet did not help
much with gait. Fluids and decrease of diltiazem, increase of
metoprolol resulted in resolution of orthostasis. Gait is
Neurology and Neurology will see her as an outpatient
(appointment made, see below).
Orthostasis
Volume depletion without appropriate response given
beta-blockade or autonomic failure. Difficult to discriminate in
context of diltiazem and metoprolol, initially, but clear that
diltiazem and desication were contributors.
Mental Status
Hypoactive delerium on background of Bingwanger changes.
Possible contributors were: Briefly restarting velafaxine,
donepizil and memantine. Disorientation of hospitalization.
Beta-blocker (less likely and reduced prior to discharge).
UTI
On UA, both bacteria and WBCs. Briefly given ciprofloxacin -
stopped when culture only grew typical flora. Will receive a 3
day course of Bactrim DS BID x3 days to .
Atrial Fibrillation
Is presently rate controlled, but was irregular at exam. This
may also contribute to orthostasis. Concern for excessive
levothyroxine not supported given normal TSH. Had dilated atria
on echo in , as likely cause. INR sub-ther. at admission so
dose increased 2.5 mg QD (rather than 3/2/3/2/3/2/2).
Renal Insufficiency
Creatinine 1.5 from baseline of about this, but has been as
low as 1.1 in this year. Has also been higher. Given
taking POs will hold off on giving further fluid until test
effect of Sinemet on orthostasis. Urine specific gravity falling
from 1.020 to 1.018, still moderately concentrated and, given
age, likely somewhat pre-renal. Improved with fluids.
Hypothyroidism
TSH WNLs during admission.
Hypertension
Well controlled. 140s when supine. Crept up when diltiazem
initially stopped and then improved when was restarted. Will
need to be followed closely.
'Congestive heart failure'
No evidence at present, but known have pulmonary hypertension.
Normal ejection fraction in .
## MEDICATIONS ON ADMISSION:
COLCHICINE - 0.6 mg Tablet - 1 Tablet(s) by mouth once a day
DILTIAZEM HCL - 240 mg Capsule,Degradable Cnt Release - 1
Capsule(s) by mouth once a day
DONEPEZIL [ARICEPT] - 10 mg Tablet - 1 Tablet(s) by mouth once a
day
LEVOTHYROXINE [LEVOXYL] - 100 mcg Tablet - 1 Tablet(s) by mouth
once a day
LISINOPRIL - 10 mg Tablet - one and half Tablet(s) by mouth once
a day
MEMANTINE [NAMENDA TITRATION PAK] - 5 mg (28)-10 mg (21)
Tablets,
Dose Pack - 1 (One) Tablets(s) by mouth as directed
MEMANTINE [NAMENDA] - 10 mg Tablet - 1 Tablet(s) by mouth twice
a
day
METOPROLOL SUCCINATE - 25 mg Tablet Sustained Release 24 hr - 1
Tablet(s) by mouth twice a day
VENLAFAXINE [EFFEXOR XR] - 75 mg Capsule, Sust. Release 24 hr -
1
Capsule(s) by mouth once a day
WARFARIN - 2 mg Tablet - 1 Tablet(s) by mouth once a day
WARFARIN [COUMADIN] - 3 mg Tablet - 1 Tablet(s) by mouth daily 3
mg
CALCIUM-VITAMIN D3-VITAMIN K [VIACTIV] - 500 mg (calcium)-500
unit-40 mcg Tablet, Chewable - 1 (One) Tablet(s) by mouth twice
a
day
## DISCHARGE MEDICATIONS:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipatinon.
6. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
.
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
9. Diltiazem HCl 90 mg Capsule, Sust. Release 12 hr Sig: One (1)
Capsule, Sust. Release 12 hr PO once a day.
10. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
11. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 3 days: Complete course on
.
## DISCHARGE DIAGNOSIS:
Primary
Multiple infarct dementia
Gait instability
Orthostatic hypotension
## SECONDARY:
Atrial fibrillation, chronic
Hypertension
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane) - actually very high fall risk and needs supervision
## DISCHARGE INSTRUCTIONS:
You came to the hospital after falling and striking your head.
We performed CT scan of your head and neck, which were normal.
X-ray of your hip - that you had bruised - did not reveal a
fracture. Your blood pressure was very low on standing and your
walking was also very unsteady. We think that these were both
likely contributors to your fall (and recently increasing
frequency of falls). While you were here we adjusted your
cardiac medications to help with your low blood pressure on
standing. We also had physical therapy evaluate your gait -
physical therapy can continue this in rehab.
In addition, you became confused while in the hospital. We
changed your medications and think that this will resolve
somewhat with this change and returning to a more normal
environment.
Your medications have changed. Please see your medication list.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "14344003", "visit_id": "23066073", "time": "2122-03-17 00:00:00"} |
14394962-RR-46 | 111 | ## HISTORY:
female with history of FAP. The patient is status post
total colectomy with end ileostomy. Additionally, the patient is status post
multiple small bowel resections and has a history of recurrent obstructions.
## FINDINGS:
Numerous surgical clips are seen throughout the abdomen with the
largest collection in the midline pelvis. There are midline loops of bowel
which are distended up to 5.1 cm and demonstrate air-fluid levels. No
intraperitoneal free air is evident. The imaged lung bases are clear.
Cardiac apex is within normal limits.
## IMPRESSION:
Dilated loops of bowel with air-fluid levels concerning for
obstruction in this patient with an end ileostomy and poor output.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14394962", "visit_id": "26128152", "time": "2113-04-11 03:11:00"} |
14097800-RR-35 | 276 | MRI BRAIN, WITH AND WITHOUT CONTRAST
## INDICATION:
male with esophageal cancer and recently diagnosed
multiple metastatic brain lesions. Evaluate for progression or new lesions.
## FINDINGS:
Multiple cystic ring-enhancing metastatic lesions predominantly
located in the gray-white matter junction involving both cerebral and
cerebellar hemispheres are again noted. magnetic susceptibility low signal may
be caused by calcification or hemorrhage. The previously noted cystic lesion
in the right inferior frontal lobe is decreased in size, measuring 1.3 cm x
1.1 cm. The lesion in the left frontal-parietal lobe is significantly
decreased in size, with a decrease in the surrounding edema as well. The
largest lesion in the left cerebellar hemisphere has also significantly
decreased in size, measuring 1.5 mm in greatest axial diameter on the current
study. Multiple bilateral hypreintense nodular punctate lesions are again
noted. Post- surgical changes in the interim are noted consistent with right
frontal burr hole.
There is no evidence mass effect or infarction. The ventricles and sulci are
normal in size. The visualized paranasal sinuses and mastoid air cells
are clear. There are no soft tissue or osseous abnormalities.
## HEAD MRA:
The intracranial vertebral and internal carotid arteries and their
major branches appear normal without evidence of stenosis, occlusion, or
aneurysm formation.
## IMPRESSION:
Multiple ring enhancing lesions consistent with known brain
metastases from esophageal primary. Enhancement may represent calcifications
or blood. Interval decrease in the right inferior frontal, left frontal-
parietal lesion, and left cerebellar lesions.
MR TUMOR VOLUME.
TECHNIQUE MR tumor volume was acquired, T1-weighted images pre- and post-
gadolinium and axial FLAIR.
## FINDINGS:
.
FLAIR vol= 2.022 cm3.
Axial T1 Gad.= 2.239 cm3.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14097800", "visit_id": "N/A", "time": "2128-09-15 12:43:00"} |
19087651-RR-25 | 212 | ## EXAMINATION:
MR KNEE W/O CONTRAST RIGHT
## INDICATION:
year old man with r knee pain severe with mechanical sx// mm
tear
## MEDIAL MENISCUS:
There is degenerative signal in the medial posterior horn,
however no tear is identified.
Lateral meniscus: There is complex tearing of the anterior horn of the lateral
meniscus, with a small meniscal fragment seen on series 4, image 9. There is
mild synovitis adjacent to the anterior horn.
## ANTERIOR CRUCIATE LIGAMENT:
Normal.
Posterior cruciate ligament: Normal.
## MEDIAL COLLATERAL LIGAMENT:
Normal.
Lateral collateral ligamentous complex: Normal.
## EXTENSOR MECHANISM:
The quadriceps and patellar tendons are intact, however
there is mild distal patellar tendinosis noted.
## CYST:
None.
Joint effusion: Small bilateral joint effusion.
Articular cartilage
## PATELLOFEMORAL:
There is full-thickness cartilage loss at the trochlear
groove with no subchondral edema seen on series 4, image 16.
## LATERAL:
There is a full-thickness cartilage defect measuring 5 x 2 mm in the
tibial plateau seen on series 6, image 10, there is no subchondral edema.
## IMPRESSION:
1. Tearing of the lateral meniscus anterior horn and body with a small
meniscal fragment in the intercondylar notch.
2. F ull-thickness focal cartilage defect overlying the tibial plateau as
well as full-thickness loss of cartilage overlying the trochlear groove of
the femur.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19087651", "visit_id": "N/A", "time": "2191-06-10 13:16:00"} |
12083367-RR-29 | 118 | ## EXAMINATION:
US MSK ELBOW RIGHT
## INDICATION:
year old man with right lateral elbow pain for 5 months. // ?
lateral epicondylosis, partial tear
## FINDINGS:
The right common extensor tendon demonstrates mild heterogeneity and
thickening when compared to the left side. There is no hypervascularity. No
full-thickness tear is identified. The possibility of a small partial tear
cannot be entirely excluded. No distension of the joint to suggest large
joint effusion.
## IMPRESSION:
Mild tendinosis of the right common extensor tendon. No full-thickness or
definite tear. The possibility of a small partial tear along the deep surface
of the tendon cannot be entirely excluded.
If additional imaging evaluation is clinically indicated, then MRI could help
for further assessment.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12083367", "visit_id": "N/A", "time": "2146-07-21 13:07:00"} |
15154188-DS-18 | 1,428 | ## ALLERGIES:
recorded as having No Known Allergies to Drugs
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
Cardiac Catheterization
s/p Coronary artery bypass grafting times three(LIMA->LAD,
SVG->Diag, OM)
## HISTORY OF PRESENT ILLNESS:
Mr. is a year old male with recently diagnosed HTN
and hyperlipidemia who has been experiencing symptoms of
substernal chest pressure/tightness with exertion that started
this past . His symptoms have occurred with activity
such as mowing the lawn or walking quickly. He denies
claudication, edema, orthopnea, PND, and lightheadedness. He was
referred to for cathetherization after a nuclear stress
that was remarkable for a large, severe fixed apical
abnormality, global hypokinesis that was more pronounced at the
apex and a dilated left ventricular cavity. His EF was 32%.
## 2. CARDIAC HISTORY:
None
3. OTHER PAST MEDICAL HISTORY:
Arthroscopic knee surgery
## FAMILY HISTORY:
No family history of diabetes or heart disease.
## GENERAL:
WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
## HEENT:
NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
## CARDIAC:
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
## LUNGS:
No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
## ABDOMEN:
Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation.
## SKIN:
No stasis dermatitis, ulcers, scars, or xanthomas.
## UNDERLYING MEDICAL CONDITION:
year old man s/p CABGx3
## REASON FOR THIS EXAMINATION:
eval for pneumothorax
Final Report
SINGLE AP PORTABLE VIEW OF THE CHEST
## REASON FOR EXAM:
Status post CABG.
Comparison is made with prior study of .
Mediastinal widening has improved. There are low lung volumes.
Mild
cardiomegaly is stable. There is no pneumothorax. Small right
pleural
effusion with adjacent atelectasis is new. Left lower lobe
retrocardiac
atelectasis is persistent. There is no evidence of CHF. Sternal
wires are
aligned.
.
## :
WED 4:48
ECHOCARDIOGRAPHY REPORT
## MRN:
TEE (Complete)
Done at 9:20:42 AM FINAL
Referring Physician
of Cardiothoracic Surg
## INDICATION:
Aortic valve disease. Congenital heart disease.
Coronary artery disease. Left ventricular function. Mitral valve
disease. Right ventricular function. Valvular heart disease.
## TYPE:
TEE (Complete)
3D imaging. Sonographer: , MD
## DOPPLER:
Full Doppler and color Doppler Location:
Anesthesia West OR cardiac
## NONE TECH QUALITY:
Adequate
Tape #: -0:1 Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.5 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.5 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 35% to 40% >= 55%
Aorta - Annulus: 2.5 cm <= 3.0 cm
Aorta - Sinus Level: *4.3 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *3.2 cm <= 3.0 cm
Aorta - Ascending: 3.1 cm <= 3.4 cm
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
## LEFT ATRIUM:
Moderate . No spontaneous echo
contrast or thrombus in the body of the . All four
pulmonary veins identified and enter the left atrium.
## RIGHT ATRIUM/INTERATRIAL SEPTUM:
Normal RA size. A catheter or
pacing wire is seen in the RA. Dynamic interatrial septum. PFO
is present. Left-to-right shunt across the interatrial septum at
rest.
## LEFT VENTRICLE:
Wall thickness and cavity were
obtained from 2D images. Mild symmetric LVH. Top
normal/borderline dilated LV cavity size. Moderate-severe
regional left ventricular systolic dysfunction.
## RIGHT VENTRICLE:
Mildly dilated RV cavity. Normal RV systolic
function.
## AORTA:
Normal ascending aorta diameter. No atheroma in ascending
aorta. Normal descending aorta diameter. Simple atheroma in
descending aorta.
## AORTIC VALVE:
Three aortic valve leaflets. Mildly thickened
aortic valve leaflets (?#). No AS. Trace AR.
## MITRAL VALVE:
Moderately thickened mitral valve leaflets.
Moderate thickening of mitral valve chordae. Trivial MR.
## VALVE:
Normal tricuspid valve leaflets with trivial
TR.
## PULMONIC VALVE/PULMONARY ARTERY:
Normal pulmonic valve leaflet.
No PS. Physiologic PR.
## GENERAL COMMENTS:
A TEE was performed in the location listed
above. I certify I was present in compliance with
regulations. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications. Suboptimal image quality - poor echo windows.
Conclusions
Prebypass
The left atrium is moderately dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium or
left atrial appendage. A patent foramen ovale is present. A
left-to-right shunt across the interatrial septum is seen at
rest. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is top normal/borderline dilated.
There is moderate to severe regional left ventricular systolic
dysfunction with severely hypokinetic anterior, lateral and
wall.. The remaining left ventricular segments are
mildly hypokinetic. The right ventricular cavity is mildly
dilated with normal free wall contractility. There are simple
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. The aortic valve leaflets are mildly
thickened. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is moderate thickening of the mitral valve
chordae. Trivial mitral regurgitation is seen. There is no
pericardial effusion.
Post bypass
is a paced and receiving an infusion of phenylephrine
and epinephrine. Biventricular systolic function is unchanged.
Aorta is intact post decannulation.
I certify that I was present for this procedure in compliance
with regulations.
Electronically signed by , MD, Interpreting
physician 13:36
## BRIEF HOSPITAL COURSE:
The was admitted on for elective cardiac
catheterization. The catherization revealed an 80% left main
stenosis, 100% mid LAD occlusion, 40% LCX stenosis, and a mid
30% RCA stenosis with and LVEF of 35%. Cardiac surgery was
consulted and the had received Plavix for the cath, so
his surgery was delayed.
On the underwent Coronary artery bypass grafting
times three with LIMA->LAD, SVG->Diag and OM. The cross clamp
time was 56 minutes and the total bypass time was 67 minutes.
He tolerated the procedure well and was transferred to the CVICU
on neo, epi, and propofol. He was extubated the night of
surgery and he was transferred to the floor on POD#1. His chest
tubes were discontinued on POD#2 and his epicardial pacing wires
were discontinued on POD#3. He was discharged to home in stable
condition on POD#4.
## MEDICATIONS ON ADMISSION:
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 80 mg
Tablet - 1 Tablet(s) by mouth daily
CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg
Tablet - 1 Tablet(s) by mouth daily
LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth daily
ASPIRIN - (Prescribed by Other Provider) - 81 mg Tablet - 1
Tablet(s) by mouth daily
## DISCHARGE MEDICATIONS:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
6. Hydromorphone 2 mg Tablet Sig: Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
Disp:*5 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 5
days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
## DISCHARGE DIAGNOSIS:
coronary artery disease
hypertension
hyperlipidemia
## DISCHARGE CONDITION:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
## DISCHARGE INSTRUCTIONS:
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "15154188", "visit_id": "22909198", "time": "2125-10-10 00:00:00"} |
19713531-RR-16 | 155 | ## EXAMINATION:
UNILAT UP EXT VEINS US LEFT
## INDICATION:
year old man with EtOH cirrhosis, variceal bleed, with LUE
edema at hand.// ? DVT
## FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins. The left internal jugular vein is patent and shows normal color flow
and compressibility.
A dual-lumen PICC is noted in the left subclavian vein extending from the
basilic vein.
There is near occlusive thrombus in the left axillary vein. Nonocclusive
thrombus is noted in the left proximal basilic vein. Occlusive thrombus is
noted in the left cephalic vein. Left brachial vein is patent.
## IMPRESSION:
Near occlusive thrombus in the left axillary vein. Nonocclusive thrombus is
noted in the left proximal basilic vein. Occlusive thrombus is seen in the
left cephalic vein.
## NOTIFICATION:
The findings were discussed with , M.D. by
, M.D. on the telephone on at 9:44 pm, 5 minutes
after discovery of the findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19713531", "visit_id": "20505170", "time": "2185-01-25 19:54:00"} |
19843867-RR-14 | 98 | ## HISTORY:
Left ankle sprain, evaluate fracture.
AP, LATERAL AND OBLIQUE VIEWS OF THE LEFT ANKLE AND TIBIA/FIBULA.
## FINDINGS:
There is a transverse fracture through the left medial malleolus.
The medial malleolus is slightly medially displaced and anteriorly rotated.
There is minimal widening of the ankle mortise. The syndesmosis is intact.
There is no fibular fracture. There is soft tissue swelling in the region of
the medial malleolus. Bone mineralization appears normal.
## IMPRESSION:
Minimally displaced medial malleolar fracture without other
fractures. Soft tissue swelling.
Findings were discussed with Dr. at approximately 12:05 p.m. on
.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "19843867", "visit_id": "N/A", "time": "2147-03-19 11:51:00"} |
10161764-RR-51 | 131 | ## HISTORY:
woman who is status post L4-S1 laminectomies and fusion.
Post-operative evaluation.
## FINDINGS:
Patient is status post posterior spinal fusion of the L4 through S1 levels.
Posterior surgical fixation rods with transpedicular screws are present at the
L4 and S1 levels. Unilateral left transpedicular screw is present at the L5
level. No significant interval change of grade 1 anterolisthesis of L5 on S1.
Lumbar vertebral bodies are normal in height. Mild sclerosis along the
sacroiliac joints. Calcified uterine fibroid projects over the lower aspect
of the left sacral ala. Moderate amount of stool within the colon.
Non-obstructive bowel gas pattern.
## IMPRESSION:
1. Status post posterior spinal fusion from the L4 through the S1 level.
Surgical hardware intact.
2. Unchanged grade 1 anterolisthesis of L5 on S1.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10161764", "visit_id": "22846190", "time": "2113-01-12 22:13:00"} |
11619904-DS-15 | 844 | ## ALLERGIES:
soy / gluten / lactose
## CHIEF COMPLAINT:
left hand pain swelling
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
I&D left fifth finger flexor sheath
## HISTORY OF PRESENT ILLNESS:
Mr. is a year old LHD male who presents to ED
with
left hand swelling, erythema and pain extending up the forearm.
Patient states he was breaking up a fight between his cat and
dog
on afternoon and was bit/scratched multiple times on both
the palmar and dorsal aspect of the hand. Originally thought it
was fine, but over the course of the next few days he noticed
the
erythema and swelling worsen and he had what he describes as low
grade fevers/chills. Yesterday he noticed the erythema and
slight
area of induration over the dorsal aspect of his forearm and
decided to go to an urgent care, who sent the patient here last
night. Of note, he also slammed the hand on a butcher's block
that evening as well, 'crushing' his .
## PAST MEDICAL HISTORY:
Celiac Disease
HTN
OA
ORIF L femur
ORIF R ankle
## GEN:
well appearing, no acute distress
## LUNGS:
breathing room air comfortably
Left upper extremity:
Swelling improved
SGILT m/r/u
Fires EPL/FPL/DIO
Fingers WPP
## BRIEF HOSPITAL COURSE:
The patient presented to the emergency department and was
evaluated by the hand surgery team. The patient was found to
have left finger flexor tenosynovitis and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on for I&D left fifth finger flexor
tendon sheath, which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The hospital course
was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
WBAT in the LUE extremity, and will be discharged on none for
DVT prophylaxis. The patient will follow up with Dr.
Fellow per routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge.
## MEDICATIONS ON ADMISSION:
Lisinopril 20mg po qd
## DISCHARGE MEDICATIONS:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Lisinopril 20 mg PO DAILY
4. OxyCODONE (Immediate Release) mg PO Q4H:PRN pain
RX *oxycodone 5 mg tablet(s) by mouth q4-6 Disp #*30
## TABLET REFILLS:
*0
5. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 6 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*12 Tablet Refills:*0
## DISCHARGE DIAGNOSIS:
left finger flexor tenosynovitis
## INSTRUCTIONS AFTER HAND SURGERY:
- were in the hospital for hand surgery. It is normal to
feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
## ACTIVITY AND WEIGHT BEARING:
- weightbearing as tolerated
## MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
## WOUND CARE:
- may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
## DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
## FOLLOW UP:
Please follow up with your Hand Surgeon, Dr. will have
follow up with 14 days post-operation for evaluation.
## PHYSICAL THERAPY:
range of motion as tolerated
weightbearing as tolerated
## TREATMENTS FREQUENCY:
Apply dry sterile dressing daily to wound.
Range of motion as tolerated
Weightbearing as tolerated
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "11619904", "visit_id": "27070845", "time": "2134-06-03 00:00:00"} |
12103504-RR-59 | 638 | ## EXAMINATION:
CTA HEAD AND CTA NECK Q16 CT NECK
## INDICATION:
History: with AMS // eval bleed, aneurysm
## DOSE:
Acquisition sequence:
1) Sequenced Acquisition 7.2 s, 18.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
1,009.3 mGy-cm.
2) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 54.5 mGy (Head) DLP =
27.2 mGy-cm.
3) Spiral Acquisition 5.2 s, 41.0 cm; CTDIvol = 31.9 mGy (Head) DLP =
1,308.4 mGy-cm.
Total DLP (Head) = 2,345 mGy-cm.
## CT HEAD WITHOUT CONTRAST:
There is a large left posterior fossa probably intraparenchymal hematoma
measuring approximately 3.4 x 4.8 cm with surrounding vasogenic edema causing
severe mass effect upon the bilateral cerebellum, left greater than right,
brainstem, ventricle, and occipital horn of the left lateral ventricle.
The mass effect is seen lifting the tentorium cerebelli superiorly and
displacing the cerebellar tonsils inferiorly, concerning for developing
tonsillar herniation. There is diffusely hypodense appearance of the
brainstem, concerning for brainstem edema.
Extensive subarachnoid hemorrhage is seen in the suprasellar cisterns,
ventricle, and bilateral insular cortex. There is prominence of the ventricles
and ventricle, concerning for obstructive hydrocephalus, although
difficult to determine the full extent given absence of prior exams. There is
mild rightward midline shift, measuring up to 4 mm. Ill-defined confluent
periventricular and subcortical white matter hypodensities are nonspecific but
likely due to chronic sequela of small-vessel ischemic disease.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
## CTA HEAD:
There is tortuous course of the left with a possible fenestration noted
along its mid-course (series 5: Image 235). There is a region of increased
contrast/hyperdensity seen superior to the dominant hematoma which may
represent a region of venous congestion (series 5: Images 259-262). However,
a dural arteriovenous malformation cannot be excluded and further assessment
could be pursued with an angiogram once patient is clinically stable.
Furthermore, there is a 2 mm focus of contrast noted posterior to the
hematoma, which may possibly represent an aneurysm (series 5: Image 251).
The vessels of the circle of and their principal intracranial branches
appear normal without stenosis, occlusion, or aneurysm formation. The dural
venous sinuses are patent.
## CTA NECK:
The carotid and vertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion. There is no evidence of internal carotid
stenosis by NASCET criteria. Mild atherosclerotic calcifications are seen in
the left carotid bifurcation.
## OTHER:
Consolidations are noted in the right upper lobe, possibly infectious versus
aspiration. There is pooling of secretions noted in the right mainstem
bronchus. There is a 9 mm enhancing nodule in the left thyroid lobe, likely
nodule. Atherosclerotic calcifications are seen along the aortic arch. There
is no lymphadenopathy by CT size criteria. An ETT and an enteric tube are
incidentally seen.
## IMPRESSION:
1. There is a 3.4 x 4.8 cm large posterior fossa intraparenchymal hematoma
with surrounding vasogenic edema with significant mass effect causing
tonsillar herniation, obstructive hydrocephalus, and brainstem edema.
2. Extensive subarachnoid hemorrhage is noted in the suprasellar cisterns,
fourth ventricle, and bilateral insular cortex.
3. Aberrant, tortuous course of the left with a possible 2 mm focus of
hyperdense contrast noted posterior to the hematoma, possibly representing
aneurysm. Region of increased contrast/hyperdensity seen superior to the
dominant hematoma may represent a region of venous congestion. However, dural
arteriovenous malformation cannot be excluded.
4. The major vessels of the circle of appear patent without stenosis,
occlusion, or aneurysm.
5. The carotid and vertebral arteries and their major branches are patent
without evidence of stenosis or occlusion. There is no ICA stenosis by NASCET
criteria.
6. Consolidations are seen in the right upper lobe, possibly infectious versus
aspiration.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12103504", "visit_id": "29098718", "time": "2114-12-17 16:25:00"} |
11252145-DS-6 | 1,233 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
Patient is a year old male who is 10 months s/p R THR with
continued left hip pain due to arthritis. He has tried
injections, physical therapy and non-operative management
without success.
## PMH:
B/L shoulder OA, HTN, Asthma, depression, anxiety,
dyslipidemia, pre diabetic, GERD, hiatal hernia
## PSHX:
R THR , left total shoulder replacement, left shoulder
arthroscopy, partial lumbar discectomy, L TKA , L knee
arthroscopy x3, R TKA , R knee arthroscopy, R L4-L5
microdiscectomy
## PHYSICAL EXAM:
Well appearing in no acute distress
Afebrile with stable vital signs
Pain well-controlled
## NEUROLOGIC:
Intact with no focal deficits
## MUSCULOSKELETAL LOWER EXTREMITY:
* Incision healing well with staples
* Scant serosanguinous drainage
* Thigh full but soft
* No calf tenderness
* strength
* SILT, NVI distally
* Toes warm
## BRIEF HOSPITAL COURSE:
The patient was admitted to the orthopedic surgery service and
was taken to the operating room for above described procedure.
Please see separately dictated operative report for details. The
surgery was uncomplicated and the patient tolerated the
procedure well. Patient received perioperative IV antibiotics.
Postoperative course was remarkable for the following:
On POD1, POD s/p left total hip - overnight, he desaturated
to on RA, 92% 4LNC, temp 102.7, chest x-ray obtained which
showed interval increase in mild pulmonary vascular congestion
and pulmonary edema, left basilar atelectasis. Given IV Lasix
10mg x 1 overnight.
On POD2, he was given another dose of IV Lasix 10mg and slowly
weaned off o2.
On POD3, he remained on RA and his hct was stable at 33.
Otherwise, pain was controlled with a combination of IV and oral
pain medications. The patient received Aspirin 325 mg twice
daily for DVT prophylaxis starting on the morning of POD#1. The
foley was removed on POD 2 and the patient was voiding
independently thereafter. The surgical dressing was changed on
POD#2 and the surgical incision was found to be clean and intact
without erythema or abnormal drainage. The patient was seen
daily by physical therapy. Labs were checked throughout the
hospital course and repleted accordingly. At the time of
discharge the patient was tolerating a regular diet and feeling
well. The patient was afebrile with stable vital signs. The
patient's hematocrit was acceptable and pain was adequately
controlled on an oral regimen. The operative extremity was
neurovascularly intact and the wound was benign.
The patient's weight-bearing status is weight bearing as
tolerated on the operative extremity with posterior precautions.
Mr is discharged to home with services in stable
condition.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Amoxicillin 500 mg PO PREOP
2. Gabapentin 800 mg PO TID
3. OXcarbazepine 300 mg PO BID:PRN Itching
4. HydrALAZINE 50 mg PO Q6H:PRN Itching
5. Zolpidem Tartrate 10 mg PO QHS
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Pravastatin 10 mg PO QPM
8. Ferrous GLUCONATE 324 mg PO TID
9. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild
10. Pantoprazole 40 mg PO Q24H
11. Aspirin 81 mg PO DAILY
12. Sertraline 50 mg PO DAILY
## DISCHARGE MEDICATIONS:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*90
## TABLET REFILLS:
*0
2. Calcium Carbonate 1000 mg PO QID:PRN Reflux
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*40 Capsule Refills:*0
4. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*40 Tablet Refills:*0
5. TraMADol mg PO Q6H:PRN pain
RX *tramadol 50 mg tablet(s) by mouth Every 6 hours prn
Disp #*60 Tablet Refills:*0
6. Aspirin 325 mg PO BID
RX *aspirin 325 mg 1 tablet(s) by mouth twice a day Disp #*56
Tablet Refills:*0
7. Ferrous GLUCONATE 324 mg PO TID
8. Gabapentin 800 mg PO TID
9. HydrALAZINE 50 mg PO Q6H:PRN Itching
10. Metoprolol Succinate XL 50 mg PO DAILY
11. OXcarbazepine 300 mg PO BID:PRN Itching
12. Pantoprazole 40 mg PO Q24H
13. Pravastatin 10 mg PO QPM
14. Sertraline 50 mg PO DAILY
## ACTIVITY STATUS:
Ambulatory - requires assistance or aid (walker
or cane).
## DISCHARGE INSTRUCTIONS:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as Colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please call your surgeon's office to schedule or confirm your
follow-up appointment.
## 7. SWELLING:
Ice the operative joint 20 minutes at a time,
especially after activity or physical therapy. Do not place ice
directly on the skin. Please DO NOT take any non-steroidal
anti-inflammatory medications (NSAIDs such as Celebrex,
ibuprofen, Advil, Aleve, Motrin, naproxen etc) until cleared by
your physician.
## 8. ANTICOAGULATION:
Please continue your Aspirin 325 twice daily
with food for four (4) weeks to help prevent deep vein
thrombosis (blood clots). Continue Pantoprazole daily while on
Aspirin to prevent GI upset (x 4 weeks). If you were taking
Aspirin prior to your surgery, take it at 325 mg twice daily
until the end of the 4 weeks, then you can go back to your
normal dosing.
## 9. WOUND CARE:
Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Staples will be removed in office in two
(2) weeks.
## 10. (ONCE AT HOME):
Home , dressing changes as
instructed, wound checks, and staple removal at two weeks after
surgery.
## 11. ACTIVITY:
Weight bearing as tolerated on the operative
extremity. Posterior precautions. No strenuous exercise or heavy
lifting until follow up appointment. Mobilize frequently.
## ACTIVITY:
Weight bearing as tolerated on the operative
extremity. Posterior precautions. No strenuous exercise or heavy
lifting until follow up appointment. Mobilize frequently
## :
Home , dressing changes as instructed, wound checks.
Staple removal to be performed in office at two weeks after
surgery.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "11252145", "visit_id": "21602628", "time": "2192-01-31 00:00:00"} |
15820214-RR-5 | 89 | ## INDICATION:
Fall on face with hyperextension of the neck. Evaluate for
fracture.
## FINDINGS:
There is no fracture or malalignment. No degenerative change. The
visualized outline of the thecal sac appears unremarkable, although CT cannot
provide intrathecal detail compared to MRI. Prevertebral soft tissue
thickness is maintained. No paravertebral hematoma is seen.
No nodules are seen in the unenhanced thyroid gland. The visualized lung
apices are clear.
## IMPRESSION:
No acute fracture or malalignment. If there is clinical concern
for ligamentous injury given the mechanism, MRI could be performed.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15820214", "visit_id": "24739216", "time": "2116-02-04 17:15:00"} |
17398597-RR-20 | 138 | ## HISTORY:
man with heart failure worsening shortness of breath.
## FINDINGS:
Frontal and lateral radiographs of the chest demonstrate well expanded lungs.
There is a slight increase in interstitial markings bilaterally. There is a a
opacity projecting over the right upper lobe, which may represent a rib
overlapping a trifurcation of a vessel versus a nodule. There is massive
cardiomegaly, increased in the prior study, which may be with reflective of
cardiomyopathy versus pericardial effusion. There is no pneumothorax or
pleural effusion.
## IMPRESSION:
1. Vague opacity of the right upper lobe may represent trifurcation of a
vessel with overlapping rib versus nodule. Recommend CT of the chest for
additional evaluation.
2. Slight increase in interstitial markings bilaterally.
## COMMENTS:
Finding number 1 was discussed with Dr. by Dr.
telephone at 4:27pm on , 10 minutes after its discovery.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17398597", "visit_id": "N/A", "time": "2179-08-20 13:42:00"} |
15277386-RR-34 | 194 | ## EXAMINATION:
CT C-SPINE W/O CONTRAST
## INDICATION:
with mechanical fall earlier today. PMH CHF with 7 pound
weight gain over past week and insidious onset worsening shortness of breath//
Rule out traumatic injury, ICH, fracture, pulmonary edema or effusions
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 5.2 s, 20.5 cm; CTDIvol = 22.8 mGy (Body) DLP = 469.1
mGy-cm.
Total DLP (Body) = 469 mGy-cm.
## FINDINGS:
Alignment is normal. No fractures are identified.Mild degenerative changes
are noted with intervertebral disc height loss, posterior osteophytes and disc
bulges resulting in mild canal narrowing most notably at C4-5. Uncovertebral
joint hypertrophy and facet joint hypertrophy resulting in up to moderate
right foraminal narrowing at C6-7. There is no prevertebral edema.
There is a 3.0 x 1.4 cm nodule which seems to arise from the right lobe of the
thyroid for which nonurgent thyroid ultrasound is suggested. Lung apices are
unremarkable.
## IMPRESSION:
No cervical spine fracture or malalignment.
A 3 cm thyroid nodule in the right for which nonurgent, outpatient thyroid
ultrasound is suggested if not already performed.
## RECOMMENDATION(S):
Outpatient thyroid ultrasound if not already performed.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15277386", "visit_id": "N/A", "time": "2168-12-19 13:34:00"} |
12965924-RR-123 | 189 | ## EXAMINATION:
L-SPINE (AP AND LAT)
## INDICATION:
year old woman with chronic back pain
## FINDINGS:
There are probably 5 non-rib-bearing vertebral bodies. Smaller T12 ribs may
not be visible on the lateral view. Lumbar lordosis is preserved. Vertebral
body heights are preserved, without compression fracture. There is mild disk
space narrowing posteriorly at L3/4 and L4/5, with equivocal trace
retrolisthesis L4/5. There is moderate to moderately severe narrowing at
L5/S1, with small marginal osteophytes and endplate sclerosis. The possibility
of a pars defect at L5 cannot be excluded, though the no is no evidence of
that on targeted review of an abdominal CT scan dated .
However, no spondylolisthesis is identified at L5/S1. Assessment of the SI
joints is limited, but grossly unremarkable .
Incidental note is made of a small, well-corticated ossific density at the
left acetabular margin, unchanged, likely an os acetabuli or possibly an old
ununited corner fracture. Right upper quadrant surgical clips noted, new
compared with
## IMPRESSION:
Discogenic degenerative changes, most pronounced at the presumptive L5-S1
level. Degenerative changes at L5-S1 have progressed compared with .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12965924", "visit_id": "N/A", "time": "2206-10-13 09:19:00"} |
19760774-DS-5 | 1,159 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
Ms. is a woman with history of
hypertension who presents with leg pain.
The patient is interviewed with the assistance of a
translator. The patient reports that she began to develop
bilateral leg pain weeks ago. She develop sored that began
to
weep fluid. The fluid was purulent and foul swelling. She
reports
that she has a severe pain in her legs, and also a cramping in
the calves. She denies fevers or chills. Denies trauma to the
leg. She saw her PCP for this issue, and was given a cream to
apply that did not help. She has been using Tylenol without much
relief of her pain. She has been able to ambulate, but is has
been more difficult due to pain.
## IN THE ED, VITALS:
97.7 103 146/68 18 100% RA
Exam notable for significant bilateral lower extremity edema and
chronic skin changes, with erythema and warmth most notable in
the left leg. Erosion along left medial ankle. Wounds/legs are
malodorous.
Labs notable for: WBC 6.6, Hb 10.8
## IMAGING:
Plain films negative for fracture; LENIs negative for
DVT
Patient given:
01:18 PO Acetaminophen 1000 mg
02:13 IV Piperacillin-Tazobactam 4.5 g
03:53 IV Vancomycin 1500 mg
03:53 IVF NS 1000 mL
On arrival to the floor, she reports that her leg pain is a
decreased from a . She implores us to help with her legs.
## ROS:
Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
## FAMILY HISTORY:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
## GENERAL:
Alert and in no apparent distress
## EYES:
Anicteric, pupils equally round
## ENT:
Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
## CV:
Heart regular, no murmur, no S3, no S4. No JVD.
## RESP:
Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
## GI:
Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
## GU:
No suprapubic fullness or tenderness to palpation
## MSK:
Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
## SKIN:
Ulcer of left medial ankle with purulent and malodorous
drainage; edema and chronic brawny skin changes of left calf;
right calf with thick crusting/scaling with appearance of
healthy
skin beneath with peau d'orange, hyperpigmentation, and
nodules/plaques
## NEURO:
Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
## DISCHARGE EXAM:
Gen - not in distress. A&Ox3
## :
S1S2 normal, no murmurs
## ABD:
No tenderness, BS normal.
## RLE:
Extensive hyperkeratotic plaques from calf to foot
with
ulceration over L medial ankle with purulent drainage. Tender to
palpation over calf
## LLE:
Ulcer with purulent discharge over left medial
malleolus and some hyperkeratotic plaques over foot. Very tender
to touch over calf.
## MICRO:
- Blood cultures negative
## - BILATERAL ANKLE/TIB/FIB:
Mild degenerative changes without
evidence of acute fracture or dislocation.
## - LENIS:
No evidence of deep venous thrombosis in the right or
left lower extremity veins to the level of the popliteal fossa.
Suboptimal imaging of the vessels in the calves limits their
evaluation.
## 3:39 PM SWAB SOURCE:
left medial ankle ulcer.
**FINAL REPORT
WOUND CULTURE (Final :
PROTEUS MIRABILIS. SPARSE GROWTH.
STAPH AUREUS COAG +. QUANTITATION NOT AVAILABLE.
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
Work-up of organism(s) listed discontinued (except
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
## SENSITIVITIES:
MIC expressed in
MCG/ML
PROTEUS MIRABILIS
| STAPH AUREUS COAG +
| |
AMPICILLIN
-----
<=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME
-----
<=1 S
CEFTAZIDIME
-----
<=1 S
CEFTRIAXONE
-----
<=1 S
CIPROFLOXACIN
-----
<=0.25 S
CLINDAMYCIN
-----
<=0.25 S
ERYTHROMYCIN
-----
<=0.25 S
GENTAMICIN
-----
<=1 S <=0.5 S
MEROPENEM
-----
<=0.25 S
OXACILLIN
-----
0.5 S
PIPERACILLIN/TAZO
-----
<=4 S
TETRACYCLINE
-----
<=1 S
TOBRAMYCIN
-----
<=1 S
TRIMETHOPRIM/SULFA
-----
<=1 S <=0.5 S
## BRIEF HOSPITAL COURSE:
Ms. is a woman with history of hypertension
who presents with leg pain found to have retention
hyperkeratosis complicated by superimposed cellulitis.
# Skin and soft tissue infection - likely Retention
hyperkeratosis based on prelim skin biopsy findings
# L medial malleolus ulcer with infection - superimposed
cellulitis
# Leg pain
Patient presented with several weeks of leg pain and skin
changes. On left leg there is a purulent and malodorous ulcer.
On both legs, there are brawny skin changes with overlying
crusting. Plain films of legs without clear bony changes. LENIs
negative for DVT. B/l pulses well-palpable. Venous stasis ulcer
is a possibility. ESR 39. Ultimately treated for cellulitis and
started on topical treatments for retention hyperkeratosis by
dermatology as below. Referral placed to dermatology for
outpatient follow up on discharge. She will continue to require
daily dressing changes on discharge. Home was arranged for
this though patient continues to be reluctant about home
visits stating she will go to nearby clinic for her daily
dressing changes instead.
- Wound care recs:
## RLE:
"urea cream or amlactin, then vaseline then wrapped in
kerlix gauze from toes to knees"
## LLE:
"mupirocin ointment then wrapped in kerlix gauze from toes
to mid calf"
-Change dressings daily
-F/U blood and wound cultures - negative blood cultures, wound
cultures positive for MSSA and proteus with sensitivities as
listed. De-scalated antibiotics to Doxy and Keflex with plan to
complete day course on discharge.
- Tylenol for pain, Tramadol for breakthrough
## CHRONIC/STABLE PROBLEMS:
# Hypertension: Not currently on any medications
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
## DISCHARGE MEDICATIONS:
1. Cephalexin 500 mg PO Q6H
RX *cephalexin [Keflex] 500 mg 1 capsule(s) by mouth four times
a day Disp #*20 Capsule Refills:*0
2. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*10 Capsule Refills:*0
3. Mupirocin Ointment 2% 1 Appl TP DAILY
RX *mupirocin 2 % 1 APP DAILY Refills:*1
4. TraMADol 25 mg PO Q6H:PRN Pain - Severe
5. Ureacin-20 (urea) 20 % topical DAILY
RX *urea [Ureacin-20] 20 % 1 APP Daily Refills:*1
## DISCHARGE DIAGNOSIS:
Retention Hyperkeratosis
Superimposed Cellulitis
## DISCHARGE INSTRUCTIONS:
Clean biopsy site with soap, water, then pad dry every day for 2
weeks. Cover with a thin layer of vaseline and perform dressing
change every day for 2 weeks.
- RIGHT lower extremity: urea cream or amlactin, then Vaseline
then wrapped in kerlix gauze from toes to knees
- for the LEFT lower extremity: mupirocin ointment then wrapped
in kerlix gauze from toes to mid calf
- Both of these dressings to be changed daily
Continue with antibiotics for another 5 days.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "19760774", "visit_id": "21856420", "time": "2182-12-12 00:00:00"} |
16686345-RR-25 | 397 | MR EXAMINATION OF THE BRAIN WITH AND WITHOUT CONTRAST,
## HISTORY:
male with ataxia, decrease left foot plantar flexion and
decreased left patellar reflex, likely Wernicke's [encephalopathy] and
possible NPH; rule out mass.
## FINDINGS:
The study is compared with the NECT of (performed for
"difficulty with ambulation"), and the remote MRI and MRA of .
Again demonstrated is prominence of the cortical sulci and fissures and the
extra-axial CSF spaces, representing global cortical atrophy. However, there
is fairly marked disproportionate ventriculomegaly, which may have progressed
slightly with the biventricular transverse measurement (at the level of the
caudate head), now 5.0 cm, was 4.75 cm and of the third ventricle (at the
level of the foramen of now 12.3 mm, was 11.7 mm. There is also fairly
confluent rim-like T2-/STIR-hyperintensity in the white matter immediately
bordering the lateral ventricular bodies; while this may reflect sequelae of
chronic small vessel ischemic disease, a contribution of transependymal
migration of CSF is not excluded.
There is now a small hemosiderin cleft at the site of the previous acute right
lenticulostriate arterial territorial infarct, involving the posterior aspect
of that putamen and corona radiata, with scattered sequelae of chronic small
vessel ischemic disease in the central pons. There is also evidence of
chronic lacunar infarction in the left cerebellar hemisphere. There is no
focus of slow diffusion to specifically suggest an acute ischemic event and
the principal intracranial vascular flow-voids, including those of the dural
venous sinuses, are preserved.
There is no space-occupying lesion and no pathologic parenchymal,
leptomeningeal or dural focus of enhancement. There is no intra- or
extra-axial hemorrhage. Incidentally noted are fairly extensive
acute-on-chronic inflammatory changes involving the right maxillary sinus, new
since the remote examination. Also incidentally noted is an apparent defect
involving the left lamina papyracea with herniation of a small amount of
intraorbital fat into that ethmoid labyrinth, likely related to remote trauma.
## IMPRESSION:
1. No acute intracranial abnormality.
2. Disproportionate lateral and third ventriculomegaly, equivocally slightly
worse since the MR examination; given the clinical context, this may
be regarded with suspicion for underlying communicating hydrocephalus.
3. Relatively stable periventricular white matter signal abnormality, which
may reflect a combination of chronic small vessel ischemic disease and
transependymal migration of CSF.
4. Acute-on-chronic inflammatory changes involving the right maxillary sinus;
correlate clinically.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16686345", "visit_id": "N/A", "time": "2194-09-13 17:41:00"} |
10611631-DS-34 | 557 | ## ALLERGIES:
aspirin / Omnipaque / Iodinated Contrast Media - IV Dye / NSAIDS
(Non-Steroidal Anti-Inflammatory Drug) / Cipro / ketamine / Bees
/ vancomycin / Reglan / daptomycin
## PERTINENT RESULTS:
11:35AM BLOOD WBC-5.8 RBC-3.19* Hgb-9.6* Hct-30.4*
MCV-95 MCH-30.1 MCHC-31.6* RDW-14.7 RDWSD-51.0* Plt
11:35AM BLOOD Glucose-93 UreaN-17 Creat-0.6 Na-139
K-4.3 Cl-107 HCO3-21* AnGap-11
11:35AM BLOOD ALT-11 AST-18 AlkPhos-45 TotBili-0.2
11:35AM BLOOD Lipase-39
11:35AM BLOOD Albumin-4.3
11:43AM BLOOD Lactate-0. RIEF SUMMARY
==============
This is a woman with a history of a PLS on warfarin,
chronic right atrial thrombus, chronic celiac stenosis with
multiple admissions for hematemesis and negative EGDs who
presents with hematemesis and abdominal pain.
Patient elected to leave AMA shortly after being admitted. She
eloped prior to being given any paperwork and prior to attending
of record evaluating patient. See below for acute issues
described in admission note.
TRANSITIONAL ISSUES
===================
[] MALS has previously thought to be the cause of her abdominal
pain and may
benefit from outpatient surgical evaluation.
[] Consider evaluation for other psychosocial triggers for
recurrent admissions
## ACUTE ISSUES:
=============
# Hematemesis
# Abdominal pain
# Median arcuate ligament syndrome (MALS)
Evaluated by vascular surgeon in the emergency department who
did not think her chronic celiac stenosis is a cause of her
abdominal pain. Her hemoglobin has remained stable in the
setting of her hematemesis. GI was consulted in the ED who did
not feel that there was a role for repeat endoscopy currently
given that patient has undergone repeated endoscopies for the
same complaint without any source of hematemesis identified.
Patient did not have any hematemesis while admitted to the
medicine floor. She left AMA prior to any further management.
# APLS
# Recurrent VTE on warfarin
# R atrial thrombus
INR 1.2 on admission; she says she has been trouble getting her
INR up at home. She is currently bridging from Lovenox back to
warfarin. She also says she has been taking Lovenox 80 mg twice
daily with PTT 29.4 on admission. She says she has an
appointment with Dr. on . Her home anticoagulation
was initially held on admission. Patient unfortunately eloped
prior to any discussion about her anticoagulation.
# GERD
Switched pantoprazole to IV while in house.
## CORE MEASURES
=============
#CODE:
full, presumed
#CONTACT:
Proxy name:
## HUSBAND PHONE:
on Admission:
The Preadmission Medication list is accurate and complete.
1. Escitalopram Oxalate 20 mg PO DAILY
2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
3. Pantoprazole 40 mg PO Q24H
4. ClonazePAM 1 mg PO DAILY:PRN anxiety attack
5. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
6. Warfarin 5 mg PO DAILY16
7. Enoxaparin (Treatment) 80 mg SC Q12H
## DISCHARGE MEDICATIONS:
1. Escitalopram Oxalate 20 mg PO DAILY
2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
3. Pantoprazole 40 mg PO Q24H
4. ClonazePAM 1 mg PO DAILY:PRN anxiety attack
5. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
6. Warfarin 5 mg PO DAILY16
7. Enoxaparin (Treatment) 80 mg SC Q12H
## DISCHARGE DIAGNOSIS:
Hematemesis
PLS on warfarin
Chronic right atrial thrombus
Chronic celiac stenosis
## DISCHARGE CONDITION:
Independent
Ambulatory
Not confused
## DISCHARGE INSTRUCTIONS:
Patient eloped prior to discharge instructions being written.
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "10611631", "visit_id": "27916029", "time": "2147-08-19 00:00:00"} |
10836446-RR-7 | 483 | ## EXAMINATION:
CT ABD AND PELVIS WITH CONTRAST
## INDICATION:
woman with 48 hr of epigastric and right lower
quadrant pain, McBurney's point tenderness, evaluate for appendicitis.
## LUNG BASES:
The partially imaged lung bases are clear. There is no pleural
or pericardial effusion.
## CT ABDOMEN:
The liver is diffusely low in attenutation consistent with hepatic steatosis.
Otherwise, the liver enhances homogeneously without evidence of concerning
focal lesions. There is no intrahepatic biliary ductal dilation. The portal
vein is patent. The gallbladder does not demonstrate evidence of stones or
wall thickening. The pancreas enhances homogeneously. There is no
peripancreatic stranding or ductal dilation. There is no splenomegaly or
focal splenic lesion. The adrenal glands are unremarkable. A tiny
subcentimeter hypodensity in the left upper renal pole is too small to
characterize (series 601b, image 43); otherwise, there is normal symmetric
renal enhancement bilaterally. There is normal symmetric prompt excretion of
contrast without evidence of hydronephrosis.
There is no evidence of bowel wall thickening or obstruction. A dilated
appendix measuring up to 8-9 mm in cross-section demonstrates possible subtle
wall edema and mucosal wall hyper enhancement along with mild surrounding
stranding/haziness of the periappendiceal fat (for example see series 2, image
57 and series 601b, image 35). Findings are suggestive of acute appendicitis.
No evidence of free intraperitoneal air or other signs of rupture or
periappendiceal abscess.
The colon is otherwise unremarkable. The abdominal aorta is normal in caliber
without evidence of aneurysm or dilation. Major proximal tributaries are
patent.
Scattered prominent retroperitoneal and mesenteric root lymph nodes are not
pathologically enlarged by CT size criteria. There is no free intraperitoneal
air or fluid.
## CT PELVIS:
There is a 2.2 x 1.7 cm right adnexal cyst with adjacent surrounding free
fluid. The free fluid immediately adjacent to the cyst is hemorrhagic in
density, but more distal in the pelvis is simple in attentuation. An IUD is
seen in grossly appropriate position within the endometrial cavity.
Otherwise, the imaged pelvic organs including the bladder and terminal ureters
are unremarkable.
## MUSCULOSKELETAL:
There is a small fat containing umbilical hernia. There is no significant
degenerative change of the imaged thoracolumbar spine. Alignment is normal.
No concerning focal lytic or sclerotic osseous lesions are seen.
## IMPRESSION:
1. Mildly dilated appendix up to 8-9mm with concern for mild wall edema and
subtle mucosal hyperenhancement with surrounding haziness/mild stranding of
the periappendiceal fat. Although there may be some component superimposed
inflammation/fluid tracking along the right gonadal veins from ruptured
adnexal cyst, in the appropriate clinical setting findings are concerning for
mild/earrly acute appendicitis. No evidence of periappendiceal abscess or
rupture.
2. 2.2 x 1.7 cm right adnexal cyst with small amount of pelvic free fluid,
fluid immediately adjacent to the cyst is hemorrhagic in density, further away
simple in density, suggests some rupture of the cyst.
3. Hepatic steatosis.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10836446", "visit_id": "24750712", "time": "2170-02-17 14:56:00"} |
13549117-RR-110 | 208 | ## INDICATION:
year old man with tachypnea, cultures growing VRE and .
MRI to rule out central cause of tachypnea // abscess? other intracranial
abnormalities?
## FINDINGS:
Motion artifact limits the evaluation of the current study.
Within these limitations, there is no evidence of hemorrhage, edema, masses,
mass effect, midline shift or infarction. There is no evidence of
intracranial abscess.
There are T2/FLAIR periventricular and subcortical white matter
hyperintensities, most consistent with chronic small vessel ischemic changes.
There is redemonstration of the prominent sulci bilaterally, most notably at
the bilateral temporal lobes, as well as age-inappropriate enlargement of the
ventricles.
There is partial opacification of the bilateral mastoid air cells. Otherwise,
the paranasal sinuses and middle ear cavities are clear. The orbits
demonstrate bilateral lens replacements. The visualized portion of the
principal vascular flow voids are preserved.
## IMPRESSION:
1. Motion artifact limits evaluation of the current study.
2. Within these limitations, there is no evidence of intracranial abscess,
hemorrhage, mass, or infarction.
3. T2/FLAIR periventricular and subcortical white matter hyperintensities are
most consistent with chronic small vessel ischemic changes.
4. As demonstrated on prior imaging, there is atrophy of the brain parenchyma
and prominence of the ventricles, greater than would be expected for the
patient's age.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13549117", "visit_id": "N/A", "time": "2121-04-16 13:26:00"} |
12770077-DS-25 | 2,706 | ## ALLERGIES:
Morphine / Demerol / Lisinopril / Levofloxacin / Heparin Agents
/ adhesive tape / Cipro / monitor leads
## HPI:
y/o female with h/o PSC s/p L hepatectomy for LHD
stricture . S/p FCMS placement across another stricture
.
She developed obstructive jaundice s/p repeat ERCP with
sludge extraction, presenting today for monitoring
post-procedure
after PTBD placement.
Past jaundice and GI unable to exchange biliary stent despite
multiple tries large hiatal and ventral hernia. She was
referred to for PTBD with balloon sweep of FCMS(fully covered
metallic stent), with scheduled procedure performed on .
On floor arrival, pt triggered for hypotension; see separate
documentation
Spoke to , uncomplicated procedure.
On floor arrival, hypotensive and dyspneic. Pain in belly
worsened over past couple of hours to mod-severe, without fever,
confusion, LH but with dyspnea associated.
FICU aware.
## ROS:
Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
## PAST MEDICAL/SURGICAL HISTORY:
PSC, biliary strictures, HTN,
T2DM, Hypothyroidism, GERD, ? HIT, h/o PE, treated for 6 months
with warfarin, h/o NSTEMI, CRE precaution
## SURGERIES:
s/p Left Hepatic lobectomy for benign biliary stricture
s/p lap Chole
s/p Back surgery/laminectomies.
s/p tubal ligation
s/p appendectomy
s/p D&C
s/p Right lower extremity venous closure
## FAMILY HISTORY:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
## PREADMISSION MEDICATIONS:
The Preadmission Medication list is accurate and complete (pt
has
handwritten home med list with
1. Aspirin 81 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. DULoxetine 60 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Levothyroxine Sodium 137 mcg PO DAILY
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Omeprazole 40 mg PO QPM
8. Pregabalin 150 mg PO TID
9. Magnesium Oxide 500 mg PO BID
10. MetFORMIN (Glucophage) 850 mg PO Q24H
11. GlipiZIDE 5 mg PO BID
12. Calcium Carbonate 500 mg PO DAILY
13. HydrALAZINE 10 mg PO BID
14. Ferrous Sulfate 325 mg PO DAILY
## VITALS:
Afebrile and vital signs significant for hypotensive,
oxygenating on 5L
## GENERAL:
Alert and in mild distress
## EYES:
Anicteric, pupils equally round
## ENT:
Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
## CV:
Heart regular, no murmur, no S3, no S4. JVP at jaw. No
edema
## RESP:
Rales in right base, diminished slightly in left.
Breathing is non-labored. Tachypnea has improved throughout the
night.
## GI:
Abdomen soft, mildly-moderately distended, TTP in RUQ though
improved; bilious fluid in PTBD bag. Bowel sounds present.
## GU:
No suprapubic fullness or tenderness to palpation
## MSK:
Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
## SKIN:
No rashes or ulcerations noted
## NEURO:
Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
## MAJOR SURGICAL OR INVASIVE PROCEDURE:
: percutaneous biliary drain placement
## BLOOD CULTURES :
no growth
Final Report
## EXAMINATION:
CT ABD AND PELVIS W/O CONTRAST ( )
## INDICATION:
s/p PTBD placement today with acute
hypotension, increasing
pain post-procedure // acute post-procedural
Additional history obtained from EMR: History of PSC, status
post left
hepatectomy for stricture in . ERCP for sludge
extraction.
New jaundice.
## TECHNIQUE:
Multidetector CT images of the abdomen and pelvis
were acquired
without intravenous contrast. Non-contrast scan has several
limitations in
detecting vascular and parenchymal organ abnormalities,
including tumor
detection.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on
PACS.
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 7.6 s, 49.4 cm; CTDIvol = 20.8 mGy
(Body) DLP =
1,015.2 mGy-cm.
Total DLP (Body) = 1,015 mGy-cm.
## COMPARISON:
CT performed at outside hospital,
MRCP , CT
## LOWER CHEST:
Opacity and consolidation at both lung bases is
demonstrated,
worse on the right, in a configuration similar to multiple prior
studies
dating back to . No pleural effusion. No pericardial
effusion. Moderate
atherosclerotic calcification of cardiac structures are noted.
## HEPATOBILIARY:
Status post left hepatectomy. An intercostal
approach
percutaneous biliary drain traverses the inferior right hepatic
lobe and
extends into a common biliary stent, terminating within the
duodenum. The
biliary stent traverses the CBD and appears to terminate within
the duodenum.
Dense material is seen outside of the CBD stent (series 3, image
27), which is
likely surgical material or sequela from prior surgery.
Along the tract of the PTBD, there is a area of relative
hypodensity measuring
approximately 5.4 x 3.1 x 5.4 cm (series 3, image 27).
Pneumobilia is noted
along the anterolateral aspect of the left hepatic lobe. No
discrete
intrahepatic biliary dilatation. There is trace subhepatic
fluid.
## 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:
Somewhat nodular appearance of the left adrenal gland
is unchanged
in . The right adrenal gland is normal.
## URINARY:
The kidneys are of normal and symmetric size. Contrast
partially
opacifies the bilateral renal collecting systems. No
hydronephrosis. There
is new right perinephric stranding with a possible small amount
of perinephric
fluid (series 3, image 38). A hypodensity within the superior
right renal
pole is consistent with a simple cyst. The bladder opacifies
and appears
unremarkable.
## GASTROINTESTINAL:
The stomach is unremarkable. There are
numerous small bowel
diverticula and focal outpouchings of air, which all appear to
be within bowel
wall. There is no bowel obstruction. Enteric contrast has
reached colon.
There is substantial diverticulosis throughout the visualized
colon. There is
thickening of colon wall along the hepatic flexure, as well as
the sigmoid
colon, however this appears similar to multiple prior studies
dating back to
. A partial loop of transverse colon is contained within a
ventral hernia
without evidence of obstruction or focal wall thickening.
## PELVIS:
There is no free fluid in the pelvis.
## REPRODUCTIVE ORGANS:
The unenhanced uterus and adnexa are
grossly unremarkable
within limits of modality. A calcification within the right
lateral uterus
likely represents a small fibroid.
## LYMPH NODES:
Multiple enlarged lymph nodes are demonstrated
along the
periaortic and portacaval stations. A right portal caval node
measures 9 mm
in the short axis and appears stable compared to the study from
. The enlarged lymph nodes are likely reactive.
## VASCULAR:
There is no abdominal aortic aneurysm. Mild
atherosclerotic disease
is noted.
## BONES:
Posterior laminectomy with rod and screw fixation of the
lower lumbar
spine is again noted. There are the extensive multilevel
degenerative changes
with anterior vertebral body height loss of the L1 vertebra
(series 6, image
43), which appears stable compared to prior study.
## SOFT TISSUES:
Anterior ventral hernia with a maximum diameter of
8.2 cm
containing a nonobstructed loop of large bowel. Inferiorly
there is an
additional fat containing diastasis measuring approximately 8.8
cm in maximum
width (series 6, image 40).
## IMPRESSION:
1. Interval placement of a right intercostal BD which
traverses the
inferior right hepatic lobe, spans the in situ common biliary
stent and
terminates within the duodenum. The CBD stent appears grossly
unchanged in
position compared to the prior study.
2. Along the tract of the PTBD there is a focal area of hepatic
hypodensity
measuring 5.4 x 3.1 x 5.4 cm within segment 5. This could
represent a
hematoma or intrahepatic collection. Further evaluation could
be obtained
with ultrasound.
3. New small amount of right perinephric and subhepatic fluid is
likely
postprocedural.
4. Small bowel and colonic diverticulosis without evidence of
acute
diverticulitis.
5. A loop of transverse colon within a superior and anterior
ventral hernia.
No bowel obstruction.
## EXAMINATION:
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT ( )
## INDICATION:
year old woman s/p PTBD with yesterday with
post-procedural severe hypotension, CT with ?hematoma vs
intrahepatic collection // CT with ?hematoma vs intrahepatic
collection
## TECHNIQUE:
Grey scale and color Doppler ultrasound images of
the abdomen were obtained.
## COMPARISON:
CT performed at 6:40 a.m.
## LIVER:
No visible hematoma. Minimal pneumobilia. Partly imaged
catheter
across the right lobe of the liver. There is no discrete fluid
collection or evidence of abscess formation. The contour of the
liver is smooth. The main portal vein is patent with
hepatopetal flow. There is no ascites.
## BILE DUCTS:
There is no intrahepatic biliary dilation.
Limited view of the right kidney demonstrates no hydronephrosis.
## IMPRESSION:
No clear correlate with the findings on the prior CT. No
evidence of
intrahepatic abscess or discrete fluid collection. No hematoma.
U/S of the
## IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
## ECHO :
The left atrial volume index is normal. The right atrium is
mildly enlarged. There is mild symmetric left
ventricular hypertrophy with a normal cavity size. There is
normal regional left ventricular systolic function.
Overall left ventricular systolic function is hyperdynamic. The
visually estimated left ventricular ejection
fraction is >=75%. Left ventricular cardiac index is normal
(>2.5 L/min/m2). There is no resting left
ventricular outflow tract gradient. Mildly dilated right
ventricular cavity with low normal free wall motion. The
aortic sinus diameter is normal for gender with a normal
ascending aorta diameter for gender. The aortic arch
diameter is normal with a mildly dilated descending aorta. The
aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets are mildly thickened
with no mitral valve prolapse. There is mild [1+] mitral
regurgitation. The pulmonic valve leaflets are not well
seen. The tricuspid valve leaflets appear structurally normal.
There is mild to moderate [ ] tricuspid
regurgitation. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
## IMPRESSION:
Mild symmetric left ventricular hypertrophy with normal cavity
size and
hyperdynamic left ventricular systolic function. Mildly dilated
right ventricular cavity with low
normal systolic function. Mild mitral regurgitation.
Mild-moderate tricuspid regurgitation. Moderate
pulmonary artery systolic hypertension.
LEFT ATRIUM ATRIUM (RA)
## PEAK E/A:
0.6
TRICUSPID VALVE (TV)
Peak Regurgitant
## LEFT ATRIUM VEINS:
Normal volume index.
RIGHT ATRIUM (RA)/INTERATRIAL SEPTUM/INFERIOR VENA CAVA (IVC):
Mildly dilated RA.
## LEFT VENTRICLE (LV):
Mild symmetric hypertrophy. Normal cavity
size. Normal regional systolic function.
The visually estimated left ventricular ejection fraction is
>=75%. Hyperdynamic ejection fraction. Normal
cardiac index (>2.5 L/min/m2). No resting outflow tract
gradient.
## RIGHT VENTRICLE (RV):
Mild cavity enlargement. Low normal free
wall systolic function.
## AORTA:
Normal sinus diameter for gender. Normal ascending
diameter for gender. Normal arch diameter.
Mildly dilated descending aorta.
## AORTIC VALVE (AV):
Mildly thickend (3) leaflets. No stenosis. No
regurgitation.
## MITRAL VALVE (MV):
Mildly thickened leaflets. No systolic
prolapse. Mild MAC. Mild chordal thickening. Mild
[1+] regurgitation.
## PULMONIC VALVE (PV):
PV not well seen. Physiologic
regurgitation.
## TRICUSPID VALVE (TV):
Normal leaflets. Mild-moderate [ ]
regurgitation. Moderate pulmonary artery
systolic hypertension.
## PERICARDIUM:
No effusion. Anterior fat pad
## ADDITIONAL FINDINGS:
Poor subcostal image quality.
## CTA CHEST IMPRESSION:
No good evidence for intrathoracic malignancy. Substantial
increase in
multifocal subsegmental atelectasis both lower lobes. There may
be a very
small region of accompanying pneumonia in the superior segment
of the right lower lobe, a common location for aspiration in the
recumbent patient.
No pulmonary emboli.
Chronic pulmonary artery enlargement suggest pulmonary arterial
hypertension which would explain perfusion abnormalities
throughout the lungs, alternatively small airway obstruction.
## SUMMARY/ASSESSMENT:
with HTN, DM2, pAF, hypothyroidism, GERD, PSC with biliary
stricture s/p L hepatic lobectomy for benign
bile duct stricture, recent hx of biliary stone/sludge requiring
removal & stenting ( ), stent cleanout ( ) who
presents from OSH with abdominal pain, jaundice and evidence of
biliary stent obstruction. Patient referred to for PTBD with
balloon sweep of biliary system for decompression on . Post
procedure, patient went into acute hypoxic respiratory failure
and profound hypotension to SBP , with leukocytosis to
and
with Cr to 1.9 (from 1.1) and elevated lactate. On ,
she
developed diarrhea, found to have c.diff colitis.
#PSC with recurrent biliary strictures s/p PTBD with drain with
. After the drain was placed, recommended capping it on
. This was done without any complications. She will go
home with the drain and follow-up with here within 2 weeks of
discharge. She was on ursodiol outpatient, initially held, but
restarted on
.
#Hypotension - resolved
#ruling out Sepsis of unknown origin- Original DDx included UTI
vs aspiration pneumonia vs biliary sepsis in the setting of
hypotension, lactic acidosis,
leukocytosis to , elevated bilirubin, hypoxic respiratory
failure and . This was thought to be translocation during the
procedure with biliary sepsis. Blood and urine cultures were
negative, and even though overlying aspiration PNA may be
possible, this was less likely. Abd US negative for fluid
collection. She received Meropenem - which
treated both biliary sepsis as well as potential aspiration
pneumonia.
#Diarrhea - She was C. diff positive and started on Vancomycin
125mg PO QID x14 days
#Acute hypoxic respiratory failure
This was thought to be secondary to aspiration pneumonia after
procedure.
She has a history of PEs in the past post laminectomy for which
she was on
coumadin for 6 months. dopplers were negative, and at that
time, could not do CTA due to . She had outpatient stress
test 2 weeks ago with Dr. was
reportedly negative, as were troponins here. She was able to
wean from 6L to 1L of O2. Once resolved, CTPA was negative
for PE. She was on RA and stable prior to discharge with no
symptoms of dyspnea.
#Hypertension
Now hypertensive with recovery over 2 days in the setting of
underlying HTN and holding of home meds. These were restarted
prior to discharge without any problems.
- secondary to sepsis and resolved
-Cr 1.1 > 1.9 > 1.6 > 0.8
#Incidental finding of possible pulmonary artery hypertension
seen on CT scan s echo - outpatient discussion
with PCP as to what
if any next steps may be helpful. There were no signs of volume
overload.
#pafib - not on AC, c/w aspirin and can discuss whether AC would
be beneficial with outpatient doctors.
risk did not change while here.
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. DULoxetine 60 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Levothyroxine Sodium 137 mcg PO DAILY
6. Multivitamins W/minerals 1 TAB PO DAILY
7. Omeprazole 40 mg PO QPM
8. Pregabalin 150 mg PO TID
9. Magnesium Oxide 500 mg PO BID
10. MetFORMIN (Glucophage) 850 mg PO Q24H
11. GlipiZIDE 5 mg PO BID
12. Calcium Carbonate 500 mg PO DAILY
13. HydrALAZINE 10 mg PO BID
14. Ferrous Sulfate 325 mg PO DAILY
15. Ursodiol 500 mg PO BID
16. TraZODone 50 mg PO QHS:PRN insomnia
## DISCHARGE MEDICATIONS:
1. Vancomycin Oral Liquid mg PO QID
RX *vancomycin 125 mg 1 capsule(s) by mouth four times a day
Disp #*22 Capsule Refills:*0
2. Aspirin 81 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Calcium Carbonate 500 mg PO DAILY
5. DULoxetine 60 mg PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
7. GlipiZIDE 5 mg PO BID
8. HydrALAZINE 10 mg PO BID
9. Hydrochlorothiazide 25 mg PO DAILY
10. Levothyroxine Sodium 137 mcg PO DAILY
11. Magnesium Oxide 500 mg PO BID
12. MetFORMIN (Glucophage) 850 mg PO Q24H
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Omeprazole 40 mg PO QPM
15. Pregabalin 150 mg PO TID
16. TraZODone 50 mg PO QHS:PRN insomnia
17. Ursodiol 500 mg PO BID
## DISCHARGE DIAGNOSIS:
Biliary obstruction requiring Percutaneous biliary tube drainage
C.diff colitis
Sepsis secondary to aspiration versus biliary source
## DISCHARGE INSTRUCTIONS:
You were admitted after your procedure for your drainage
placement. Unfortunately after the procedure you had developed a
very low blood pressure along with low oxygen levels requiring
IV fluid hydration and supplemental oxygen. Your kidneys also
got affected by this but have recovered back to normal function.
You were treated for an infection, likely from an aspiration
pneumonia versus an infection from your gallbladder for 5 days.
During your stay, you developed diarrhea due to a c.diff
infection and are to continue with antibiotics for this as
instructed.
Please see your PCP 1 week and follow up with your
Gastroenterologist, Dr on as scheduled
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "12770077", "visit_id": "24878991", "time": "2146-02-27 00:00:00"} |
17023599-RR-5 | 287 | ## INDICATION:
Patient is a female with history of recurrent
unexplained pancreatitis. Please evaluate pancreatic parenchyma and ductal
system.
## EXAMINATION:
MRCP with and without intravenous contrast.
## FINDINGS:
Within the ventral aspect of the head of the pancreas, there is a geographic
region of T1 hypointensity seen more readily after post-contrast
administration; however, that also demonstrates diffuse drop-out in signal
intensity on out-of-phase images that is compatible with a geographic region
of focal fatty infiltration. The focal fat makes detection of an underlying
lesion difficult to ascertain, and in the setting of multiple episodes of
unexplained pancreatitis, an underlying exclusion cannot be excluded. No other
concerning pancreatic lesions. The pancreatic duct is normal with no
pancreatic ductal dilatation identified.
There are several areas of differential perfusion noted within the right
hepatic lobe. No focal liver lesions are identified. There is no intra- or
extra-hepatic biliary dilatation with the common bile duct normal in caliber
and configuration. The main portal vein and its major branches are patent.
The patient is status post cholecystectomy. The spleen, both adrenal glands,
and visualized loops of intra-abdominal small and large bowel are normal.
Within both kidneys, there are several subcentimeter T2 homogeneously
hyperintense thin-walled lesions that have characteristics compatible with
simple cysts. There is no mesenteric or retroperitoneal lymphadenopathy.
There is no intra-abdominal free fluid. The visualized osseous structures are
unremarkable with no suspicious osseous lesions.
## IMPRESSION:
Focal fatty infiltration involving the ventral aspect of the
pancreatic head. In the setting of the focal fatty infiltration, detection of
an underlying lesion is difficult, and with reported multiple unexplained
episodes of pancreatitis, clinical correlation with EUS is recommended for
detection of an underlying occult lesion.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17023599", "visit_id": "N/A", "time": "2185-05-02 13:41:00"} |
17238466-RR-10 | 237 | ## INDICATION:
woman with cranial nerve 5 and cauda equina
enhancement. History of abnormal breast tissue. Rule out cancer or mass.
## DOSE:
Acquisition sequence:
1) Spiral Acquisition 2.3 s, 36.7 cm; CTDIvol = 11.2 mGy (Body) DLP = 411.8
mGy-cm.
2) Spiral Acquisition 4.3 s, 68.2 cm; CTDIvol = 12.3 mGy (Body) DLP = 836.1
mGy-cm.
3) Spiral Acquisition 2.2 s, 34.7 cm; CTDIvol = 10.9 mGy (Body) DLP = 377.9
mGy-cm.
4) Stationary Acquisition 3.8 s, 0.5 cm; CTDIvol = 21.1 mGy (Body) DLP =
10.5 mGy-cm.
Total DLP (Body) = 1,636 mGy-cm.
** Note: This radiation dose report was copied from CLIP (CT ABD AND
PELVIS W AND W/O CONTRAST, ADDL SECTIONS)
## FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL:
Visualized thyroid is unremarkable.
No supraclavicular or axillary lymphadenopathy. Please note that the breast
tissue should be evaluated with mammography.
## PLEURA:
No pleural effusion. No pneumothorax.
## 1. PARENCHYMA:
Lungs demonstrate diffuse ground-glass opacification, likely
due to low inspiration. Evaluation of small pulmonary nodules is limited.
Calcified granuloma in the right upper lobe.
## 2. AIRWAYS:
Central airways are widely patent.
## 3. VESSELS:
The thoracic aorta is unremarkable. Although not a dedicated
study, no central pulmonary embolism is identified.
## CHEST CAGE:
Deformity of the right humerus may relate to humeral neck
fracture. Suspicious osseous lesion.
## IMPRESSION:
No evidence of malignancy in the chest.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17238466", "visit_id": "27858010", "time": "2131-10-05 20:03:00"} |
17782175-RR-25 | 153 | ## INDICATION:
man with history of carotid stenosis many years ago,
query carotid stenosis.
## FINDINGS:
There is mild homogeneous plaque in the internal carotid arteries bilaterally.
On the right side, the peak systolic velocity in the common carotid artery is
89 cm/sec, the peak in the ICA proximally is 66 cm/sec, in the mid portion is
48 cm/sec and distally is 48 cm/sec. This yields an ICA/CCA ratio of 0.74,
within normal limits. Flow in the right vertebral artery is antegrade.
The peak systolic velocity in the left common carotid artery is 83 cm/sec, in
the left ICA proximally is 64 cm/sec, in the mid portion 52 cm/sec and
distally 79 cm/sec. This yields an ICA/CCA ratio of 0.95, within normal
limits. The left vertebral artery demonstrates antegrade flow.
## IMPRESSION:
No evidence of hemodynamically significant stenosis in either
carotid artery.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17782175", "visit_id": "N/A", "time": "2147-12-03 09:44:00"} |
14216592-RR-25 | 96 | ## EXAMINATION:
KNEE (AP, LAT AND OBLIQUE) RIGHT
## INDICATION:
with R knee pain/swelling and difficulty ambulating.// r/o
fracture or other acute causes of knee pain r/o fracture or other acute
causes of knee pain
## FINDINGS:
No fracture or dislocation is seen. There are mild degenerative changes in the
patellofemoral and medial compartment with bony spurring. A subchondral
lucency in the femoral condyle may represent subchondral cystic change. There
is no knee joint effusion. There is normal osseous mineralization. No
suspicious lytic or sclerotic lesions are identified.
## IMPRESSION:
No acute fracture or dislocation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14216592", "visit_id": "N/A", "time": "2110-01-12 23:34:00"} |
16679284-RR-40 | 106 | ## INDICATION:
Right lower quadrant pain. Status post a remote appendectomy.
Evaluate for ovarian abnormalities.
## FINDINGS:
The uterus measures 8.0 x 3.4 x 4.7 cm. There is a 1.8 x 2.1 x 2.0
cm fundal fibroid. No other focal uterine lesions are identified. The
fibroid is somewhat distorting the endometrium. The visualized portions of
the endometrium are normal and measure 3 mm.
Neither ovary is definitely visualized. There are no large adnexal masses.
There is no free fluid in the pelvis.
## IMPRESSION:
1. 2.1 cm fundal fibroid.
2. No adnexal abnormalities, though the ovaries are not definitely
visualized.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16679284", "visit_id": "N/A", "time": "2133-02-18 12:51:00"} |
15307100-RR-15 | 227 | ## INDICATION:
yo woman with medical history of HTN, HLD, pulmonary
asbestosis, and seasonal allergies presenting as a code stroke intubated and
sedated after 3 focal motor seizures with subsequent RT arm weakness// Please
assess for stroke vs infection
## FINDINGS:
Study is severely degraded by motion, especially on postcontrast imaging.
Within these confines:
There is no evidence of acute intracranial infarction or hemorrhage.
Ventricles and sulci are prominence likely secondary to age related
involutional changes. Periventricular and deep subcortical FLAIR white matter
hyperintensities are likely secondary to chronic microangiopathy. Subtle
gyriform high FLAIR signal abnormality is seen along the cortex in the left
parietal lobe, series 11, image 14. No definite enhancement or low signal on
the gradient echo sequences is seen in this region. No definite abnormal
enhancing lesions are identified.
Mild mucosal sinus thickening is seen involving the ethmoid air cells, fluid
opacification is seen within the bilateral mastoid air cells, and fluid in
patient's nasopharynx may be related to intubation status. The patient is
status post bilateral lens replacement surgery.
## IMPRESSION:
1. Study is severely degraded by motion.
2. Nonspecific nonenhancing left parietal gyriform versus sulcal signal
abnormality. Differential considerations include meningitis, high oxygen
ventilation with small subarachnoid hemorrhage less likely. If concern for
new subarachnoid hemorrhage since and neck CTA, consider
noncontrast head CT.
3. No acute intracranial hemorrhage or infarction.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15307100", "visit_id": "20317861", "time": "2137-10-21 15:37:00"} |
11565875-RR-48 | 198 | ## EXAMINATION:
CT HEAD W/O CONTRAST
## INDICATION:
History: with speech difficulty, facial droop.
## FINDINGS:
There is an ill-defined mass lesion in the posterior left frontal lobe, with a
partially hyperdense superficial solid component measuring 2.8 x 2.3 cm (2:20)
and a 4 x 2.8 cm cystic component anteromedially. There is moderate
surrounding vasogenic edema. Body of the left lateral ventricle is slightly
effaced. There is no shift of midline structures. An additional hyperdense
lesion with central calcification is present in the inferior right temporal
lobe measuring 1.4 x 1.0 cm, with minimal vasogenic edema. Multiple
additional punctate hyperdensities, many of which appear to represent
calcifications, are also seen scattered throughout the brain. The basal
cisterns are patent.
No suspicious lytic or sclerotic bone lesions are seen. Partially imaged
paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
## IMPRESSION:
Apparent solid and cystic mass lesion in the left frontal lobe with moderate
vasogenic edema. Small partially calcified mass lesion in the right temporal
lobe. Multiple scattered parenchymal calcifications. These findings may
represent malignancy, or less likely an infectious process. Recommend MRI with
and without contrast for further evaluation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "11565875", "visit_id": "23066140", "time": "2196-09-30 09:13:00"} |
16417689-RR-42 | 532 | ## INDICATION:
year old woman with metastatic NSCLC presents with
encephalopathy and C2 lesion on CT scan // Characterize C2 lesion. Eval
etiology of encephalopathy. Eval other known sites of prior spinal mets
## FINDINGS:
The patient is status post right parieto-occipital craniotomy and resection of
a right parietal lobe mass with chronic blood products in the postoperative
bed. The thin, curvilinear enhancement surrounding the resection cavity in the
right parieto-occipital lobes has decreased. There is no new or nodular
enhancement surrounding the resection cavity. The confluent T2/FLAIR
hyperintense signal surrounding the resection cavity in the right occipital,
temporal, and parietal lobes is unchanged from most recent CT examination, but
increased from . The mild dural thickening and enhancement
underlying the craniotomy site is unchanged.
The 3 mm enhancing lesion in the right cerebellar hemisphere is decreased in
size, previously measuring 5 mm on 700:71. The 2 mm enhancing lesion in the
right frontal lobe on 700:117 has decreased in size, measuring 2 mm,
previously measuring 3 mm. The 3 mm enhancing lesion in the right posterior
temporal lobe on 700:98 has decreased in size, measuring 3 mm, previously
measuring 8 mm. This lesion demonstrates susceptibility. The previously seen
subependymal lesion along the left lateral ventricle and enhancing lesion in
the left postcentral gyrus have resolved.
A 1.0 x 1.4 x 1.5 cm new, round, enhancing, intradural extramedullary mass
within the left anterolateral thecal sac at C2-C3 flattens, remodels, and
posteriorly displaces the spinal cord, resulting in moderate spinal canal
stenosis.
Sulcal FLAIR hyperintensity in the bilateral frontoparietal lobes without
susceptibility is likely related to the patient's intubated status and the
paramagnetic effect of dissolved oxygen.
There is no evidence of acute hemorrhage, midline shift or infarction. The ex
vacuo dilatation of the temporal horn of the right lateral ventricle is
unchanged.
There is moderate mucosal thickening in the bilateral ethmoid sinuses. The
mastoid air cells are clear. The orbits are unremarkable.
The 7 mm aneurysm of the anterior communicating artery, projecting anteriorly,
and 4 mm aneurysm of a left proximal M3 segment on 700:91 are unchanged from
the prior examination.
## IMPRESSION:
1. New intradural, extramedullary, enhancing mass within the left
anterolateral thecal sac at C2-C3, which flattens, displaces, and remodels the
spinal cord, causing moderate spinal canal stenosis, consistent with
metastases.
2. Postsurgical changes with interval decrease in the thin, curvilinear
enhancement surrounding the resection cavity as well as confluent T2/FLAIR
hyperintense signal surrounding the resection cavity, unchanged from the most
recent CT examination, but progressed from , most likely
reflecting posttreatment changes. No new or nodular enhancement surrounding
the resection cavity to suggest residual or recurrent disease.
3. Interval resolution of the metastases along the left lateral ventricle and
left postcentral gyrus and interval decrease in the size of the metastases in
the right cerebellar hemisphere, right posterior temporal lobe, and right
frontal lobe.
4. Unchanged 7 mm aneurysm of the anterior communicating artery and 4 mm
aneurysm of the left proximal M3 segment.
## NOTIFICATION:
The findings were discussed with Dr. . by
, M.D. on the telephone on at 9:46 AM, 30 minutes after discovery
of the findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "16417689", "visit_id": "22024717", "time": "2162-10-15 18:37:00"} |
14543908-RR-29 | 367 | ## EXAMINATION:
MR FOOT CONTRAST RIGHT
MRI of the right foot with and without contrast.
## INDICATION:
year old woman with diabetic peripheral neuropathy c/b b/l
foot ulcers s/p L. heel debridement with partial calcanectomy for L. heel
osteomyelitis ( ) and recent debridement/closure of L. heel who presents
with pain and elevated CRP. ulcer ( ) //osteomyelitis?.
## FINDINGS:
There is an ulcer along the medial aspect of the heel (3:25) with edema and
associated enhancement of subcutaneous tissue, likely representing cellulitis.
There is hypointense signal on T1 weighted imaging and the inferior posterior
aspect of the calcaneus (05:11) with associated bone marrow edema compatible
with osteitis. There is no evidence of cortical irregularity of the
calcaneus.
There is an ovoid T2 hyperintense focus without enhancement (0:10) adjacent to
the anterior subtalar joint likely representing a ganglion. There are small
effusions of the tibiotalar and posterior subtalar joints. There is a small
amount of fluid in the calcaneocuboid joint.
This musculoskeletal infection study is not tailored for assessment of the
ankle ligaments.
There is low-grade intrasubstance tear of the Achilles tendon approximately
2.5 cm proximal to the insertion (06:12) on a background of tendinosis. There
is an early split tear of the peroneus brevis tendon and tendinosis of the
peroneus longus tendon. The calcaneofibular ligament is thinned. The
posterior and anterior talofibular ligaments are intact. The syndesmotic
ligaments appear intact.
The plantar fascia is thickened. There is moderate muscle atrophy in keeping
with diabetic changes.
There is scattered mild degenerative changes of the hindfoot.
There is additional are nonenhancing subcutaneous edema about the ankle, with
areas of confluent edema overlying the medial malleolus. No definitive
drainable Fluid collection rim enhancing abscess seen however.
## IMPRESSION:
Shallow ulcer at the medial aspect of the heel of the right foot with
associated edema and enhancement of the soft tissues, consistent with
cellulitis. There is mild bone marrow edema of the underlying inferior
posterior calcaneus with associated enhancement likely representing osteitis.
However given the severity of the overlying cellulitis, early osteomyelitis is
not completely excluded. Follow up calcaneal grafts in days can be
considered. There is no drainable fluid collection or rim enhancing abscess
seen.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "14543908", "visit_id": "26964121", "time": "2148-06-12 16:18:00"} |
10283304-RR-64 | 174 | ## FINDINGS:
In the lumbar spine, a combination of degenerative change and severe scoliosis
markedly limits evaluation and this measures cannot be used.
In the right femoral neck bone mineral density was measured as 0.817 g/cm2
corresponding to a T-score of -1.6 and a Z-score of 0.1. In the left femoral
neck bone mineral density was measured as 0.782 g/cm2 corresponding to a
T-score of -1.8 and a Z-score of -0.2. No statistically significant change
when compared to the prior study
Additional measurements were obtained in the right forearm. Bone mineral
density in the radius segment measured 0.594 g per cm 2. This corresponds
to a T-score of-1.6 and a Z-score of-0.1. There has been no statistically
significant interval change in the forearm measurements when compared to the
prior study.
## IMPRESSION:
Overall the patient has osteopenia in accordance with WHO criteria. There has
been no significant interval change when compared to the prior study
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10283304", "visit_id": "N/A", "time": "2187-07-22 13:16:00"} |
17710401-RR-177 | 413 | ## EXAMINATION:
CT LOW EXT W/O C RIGHT
## INDICATION:
year old woman with diabetes and R distal tib/fib fx // post
ex-fix. Evaluate mid-tibia down to foot. Injury reportedly occurred
.
## FINDINGS:
External fixator is partially imaged spanning the tibial diaphysis, calcaneal
tuberosity and first metatarsal. Visualized external fixator components are
intact without complication.
There is redemonstration of a displaced in severely comminuted fracture of the
distal tibia and fibula. Articular fracture fragments maintain near-anatomic
alignment in relation to the weight-bearing axis, however craniocaudal
inter-fragmentary gaps measure up to 18 mm at the tibia and 14 mm at the
fibula. Principal fracture fragments demonstrate marginal sclerosis,
typically representing some degree of subacuity. Intra-articular involvement
at the plafond is multifragmentary, with mild residual incongruity and
multiple small intra-articular fracture fragments. The ankle mortise remains
symmetric and the tibiofibular syndesmosis is not widened.
Midfoot fusion hardware spanning the talar neck, fragmented navicular as well
as medial and intermediate cuneiforms appears intact without complication.
There is chronic nonunion of the medial an lateral navicular fracture
fragments. There is severe degenerative change across the Chopart and
Lisfranc joints, likely representing combination of posttraumatic and
potentially neuropathic arthrosis. Osseous mineralization is diffusely
decreased. Diffuse fatty atrophy of all the muscles diffuse subcutaneous soft
tissue edema.
Evaluation of soft tissues is limited by the inherently poor soft tissue
contrast of CT. Within the limitation the peroneal, posterior tibial and
flexor digitorum superficialis tendons closely approximate fractures of the
fibula and medial malleolus, respectively, without evidence of entrapment. No
retracted full-thickness tendon tear is identified. There is diffuse and
severe muscular fatty atrophy throughout the foreleg and visualized foot.
Diffuse subcutaneous reticulation likely represents mixed edema and/or
hemorrhage. Dystrophic mineralization of the lateral and medial ankle
ligaments likely represents sequelae of remote and repeated trauma.
## IMPRESSION:
1. External fixation of severely comminuted intra-articular fractures of the
distal tibial plafond and fibula (pilon fracture).
2. Articular fracture fragments maintain near-anatomic alignment relative to
the weight-bearing axis, but with significant craniocaudal distraction of
fracture fragments at both sites.
3. Marginal sclerosis of fracture fragments suggests some degree of subacuity.
Careful correlation with any and all recent trauma is recommended in this
patient with diabetes and peripheral neuropathy.
4. Pre-existing medial midfoot fusion hardware with chronic navicular nonunion
and severe midfoot degenerative arthrosis, likely a combination of
posttraumatic and neuropathic arthropathy.
5. Severe fatty atrophy of the foreleg musculature.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17710401", "visit_id": "N/A", "time": "2149-07-15 00:12:00"} |
17854152-RR-6 | 413 | ## HISTORY:
History of status post resection with new pulmonary mass and
nodules, CT uploaded from outside hospital for source of mass.
## PHYSICIANS:
Dr. , abdominal radiology attending; Dr.
, abdominal radiology fellow; and Dr. , radiology
resident.
## PROCEDURE:
The procedure, including risks, benefits and alternatives were explained to
the patient and after a detailed discussion, informed written consent was
obtained from the patient. A preprocedure timeout using three patient
identifiers was performed as per protocol.
The patient was placed in a prone position on the CT scan table. The site of
entry was marked. 15 cc of 1% lidocaine were administered to the superficial
and deep subcutaneous tissues for local anesthetic effect. Under CT guidance,
a 17 gauge, 13.8 cm Bard coaxial needle was introduced into the left upper
lung mass via a posterior approach and an 18 gauge Bard biopsy device was used
to obtain a core specimen x2 passes. Cytology was present and deemed the
specimens adequate. The needle was withdrawn. There was a small amount of
hemorrhage anterior to the lesion within the lung after the second biopsy.
The patient was briefly coughing immediately post-biopsy; the procedure was
otherwise well-tolerated.
Moderate sedation was provided by administrating divided doses of fentanyl
throughout the total intraservice time of 35 minutes by an independently
trained radiology nurse during which the hemodynamic parameters were
continuously monitored. A total of 50 mcg of fentanyl was administered to the
patient.
Post-procedure orders were written in the medical record including
follow-up chest x-rays one hour and three hours post-biopsy.
Pre-procedure non-contrast CT scan of the upper chest was performed and
demonstrated stable calcification in the left lobe of the thyroid gland. The
2.6 cm left upper lobe mass is once again seen. There is left hilar
adenopathy. In addition, there are several small bilateral lung nodules, the
largest in the right middle lobe measures 9 mm (3:24). There is minimal
thickening of the right pleura. There are mild-to-moderate atherosclerotic
changes of the thoracic aorta. There is an aberrant right subclavian artery.
The attending radiologist, Dr. , was present throughout the entire
duration of procedure.
## IMPRESSION:
Technically successful CT-guided core biopsy of the left upper lung mass.
Cytology was present and deemed the specimen adequate. Small amount of
hemorrhage within the lung anterior to the lesion post-biopsy.
The findings were conveyed to Dr. , at 5:30 p.m. on , 10 minutes after the the procedure.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17854152", "visit_id": "28058443", "time": "2192-01-12 15:42:00"} |
17213189-RR-9 | 130 | AP PORTABLE CHEST, AT 19:19 HOURS
## HISTORY:
Shortness of breath. Has history of lymphoma, on chemotherapy.
.
## FINDINGS:
A very large pleural effusion has developed on the right in the
long interval since the prior exam. The previously noted dense consolidation
in the right lower lung may be present but would be obscured by this large
effusion. The aerated right upper lung is clear. The left lung is largely
clear as well except for a linear scar radiating from the hilum, similar to
the prior study. Aortic tortuosity is again evident. Cardiac silhouette size
is difficult to discern but likely is within normal limits for size. No left
effusion is evident. There is no pneumothorax.
## IMPRESSION:
Interval development of very large right pleural effusion. Right
basilar consolidation not excluded.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "17213189", "visit_id": "24311099", "time": "2155-05-06 18:53:00"} |
10803137-RR-8 | 145 | ## EXAMINATION:
CT HEAD W/O CONTRAST
## INDICATION:
year old woman s/p chairi decompression and C1 laminectomy.
// Please include upper cervical spine - To be completed 3 hours post -op
approx 4PM
## FINDINGS:
The patient is status post occipital craniotomy for Chiari decompression. The
patient is also status post C1 laminectomy, however C1 is not completely
evaluated on this exam. Expected pneumocephalus is seen in the surgical bed
and scattered throughout the cranium. There is no evidence of hemorrhage,
edema, mass effect, or infarction. The ventricles and sulci are normal in size
and configuration. The basal cisterns appear patent and there is preservation
of gray-white matter differentiation.
No fracture is identified. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The globes are unremarkable.
## IMPRESSION:
Expected postoperative changes status post Chiari decompression. C1 not
completely evaluated on this exam.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10803137", "visit_id": "24238084", "time": "2130-08-12 15:56:00"} |
12133266-RR-33 | 421 | ## INDICATION:
male with renal stones.
## CT OF THE ABDOMEN:
There is minimal bilateral subsegmental atelectasis at the
lung bases. No pleural effusion, nodule, or opacity is identified in the lung
bases. Coronary calcifications are noted.
There are multiple bilateral renal calculi. The overall burden of calculi on
the left is essentially unchanged. There is a large conglomerate of
calcifications in the left lower pole anterior calices which measures up to 2
cm. Peripelvic cysts are again noted on the left. Numerous renal calculi are
seen in the right kidney, the largest of which measures 5 mm. Although it is a
non- contrast study, it appears that the right upper pole is dilated, and more
likely represents a dilated upper pole collecting system than interval
development of a peripelvic cyst since . Calcifications below the
dilated collecting system, but in the infundibulum, suggest the presence of
infundibular stenosis or possible obstruction by one of the stones. No calculi
are identified in the expected course of the ureters bilaterally. There is no
evidence of hydroureter bilaterally.
The non-opacified stomach, liver, pancreas, spleen, adrenal glands, small and
large bowel are unremarkable. No free air or fluid is seen within the
abdomen. No mesenteric or retroperitoneal lymphadenopathy is identified. Mild
atherosclerotic calcifications are noted in the abdominal aorta and iliac
arteries, as before.
CT OF THE PELVIS WITHOUT IV CONTRAST:
The bladder, prostate, seminal
vesicles, rectosigmoid colon, and loops of small bowel are unremarkable. There
is no pelvic or inguinal lymphadenopathy or free fluid in the pelvis.
## OSSEOUS STRUCTURES:
Diffuse osteopenia and fixation of the right femoral neck
with a dynamic compression screw are again noted. Degenerative changes of the
lower thoracic and lumbar spine are also again noted and unchanged in
appearance. There are compression fractures of the L1 and L2 vertebral bodies.
The large Schmorl's node in the superior endplate of the L2 vertebral body is
again noted. Vacuum discs are seen at L3-4 and L4-5 with endplate sclerosis
and large anterior osteophyte formation. There is expansion of the right
anterolateral recess and neural foramen of L3-4 which is unchanged from prior
and may represent dural ectasia.
## CT RECONSTRUCTIONS:
Coronal and sagittal reconstructions were essential in
delineating the anatomy and pathology.
## IMPRESSION:
1. Bilateral renal calculi. Unchanged overall burden compared to on
the left. Infundibular stenosis or obstructing stone with upper pole
collecting system dilation in the right kidney.
2. Severe degenerative changes of the lower thoracic and lumbar spine as
described above which are stable since .
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12133266", "visit_id": "N/A", "time": "2160-09-22 12:31:00"} |
13018436-RR-25 | 156 | ## INDICATION:
year old woman with left PTX post lung Bx. For pigtail
insertion into left pleural space. // Drain left PTX
## PROCEDURE:
CT-guided drainage of left pneumothorax collection.
## OPERATORS:
Dr. fellow and Dr.
radiologist. Dr. supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
## SEDATION:
Moderate sedation was provided by administering divided doses of 2
mg Versed and 150 mcg fentanyl throughout the total intra-service time of 23
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
## FINDINGS:
Left apical pneumothorax.
## IMPRESSION:
Successful CT-guided placement of pigtail catheter into the left
apical pneumothorax. Approximately 300 mL air was aspirated which resulted in
resolution of the pneumothorax. The patient will be admitted to the thoracic
surgery service for ongoing observation.
## NOTIFICATION:
These findings were discussed with the thoracic surgery
fellow, Dr. , following completion of this exam.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "13018436", "visit_id": "23582857", "time": "2171-07-06 18:23:00"} |
12316664-RR-43 | 171 | HEAD CT WITHOUT CONTRAST, AT 1251 HOURS.
## HISTORY:
Self-limited new onset visual changes with trigeminal first division
left tingling.
## FINDINGS:
The extracalvarial soft tissues are unremarkable. The calvarium
and skull base are intact without fracture or suspicious osseous lesion. The
included paranasal sinuses and mastoid air cells are clear. The globes are
intact.
Intracranially, the ventricles are midline and normal in size and
configuration. The cortical sulci and subarachnoid cisterns are likewise
unremarkable. The gray matter-white matter interface is well defined. There
is no intracranial hemorrhage or CT evidence of acute cortical stroke. There
is, however, markedly ectatic basilar artery with prominent at the tip to
approximately 5 mm in diameter.
## IMPRESSION:
No definite acute intracranial process. However, the basilar
artery tip is markedly prominent. While not diagnostic on non-contrast head
CT, a basilar tip artery aneurysm cannot be entirely excluded. If indicated,
CTA or MRA is recommended for further evaluation. Findings and
recommendations were discussed with Dr. at 3 p.m. on the day of study.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12316664", "visit_id": "N/A", "time": "2191-02-13 12:51:00"} |
16462650-DS-8 | 1,544 | ## ALLERGIES:
No Known Allergies / Adverse Drug Reactions
## HISTORY OF PRESENT ILLNESS:
recent admission to for PNA and septic shock
discharged on , currently residing at
facility presents for evaluation of orthostatic hypotension.
For his PNA, was initially on vancomycin and Zosyn that was
switched to doxycycline and augmentin. was also volume
overlaoded for which received lasix. also received 3 during that hospitalization for severe anemia secondary to
myelodysplastic syndrome with appropriate increase per dc
summary (hgb 6->9). In addition, it was noted on CT that has
Gluteal Soft tissue bleeding and his coumadin was discontinued
in the setting of thrombocytopenia due to MDS. was discharged
on augmentin for extra 5 days, doxycycline for extra 9 days
(last dose .
was having "loose stools" and on had negative C diff
toxin. was started empirically on PO vancomycin 250 mg q 6 hr
x14 days (last dose prior to knowledge about negative
stool C diff toxin. Pt had 1 normal BM yesterday.
Patient states that earlier on day of presentation to ,
was feeling well until eating breakfast when felt slightly
nauseated. vomited times one, nonbloody/nonbilious. Patient
had vital signs taken at that time, revealing orthostatic
hypotension dropping from approximately SBP 110 to SBP 70, lying
to standing. In addition, patient was found to be in A. fib to
the 120s.
has appt with device clinic to check on his pacemaker
.
In the ED Initial Vitals were 97.8 107 100% 4L NC.
Patient denies chest pain, palpitations, further nausea, fevers,
chills, cough, sputum production, shortness of breath.
otherwise feels well. EKG showed AFib with rate of 120's. Labs
were notable for: PTT: 38.9, INR: 1.3, Cr 1.2 since
, Na 130 (125-138 since , K 4.1, Lactate 1.1, Plt
54 (34-123 since , H/H 10.3/31.8 (Hgb since
, Hct 24.7-29.7 since . Blood cultures were sent.
UA showed WBC of 10 but no bacteria or nitrite or leuks. Pt
received 1 L NS and dilt 30 mg po x1 and bactrim PO x1 (? UTI
though UA showed only 10 WBC). CXR per prelim read showed
(compared to New small-to-moderate left greater than right
pleural effusions and central vascular congestion without frank
interstitial edema. Vitals prior to transfer were: 98.0 107
117/82 18 98%.
It's noted at rehab notes that has fair PO intake.
On review of systems, 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. denies recent fevers, chills or rigors.
denies exertional buttock or calf pain. All of the other
review of systems were negative.
## . CARDIAC RISK FACTORS:
NO Diabetes, NO Dyslipidemia, NO
Hypertension
## 2. CARDIAC HISTORY:
-CABG:
NONE
-PERCUTANEOUS CORONARY INTERVENTIONS: NONE
-PACING/ICD: pacemaker
## 3. OTHER PAST MEDICAL HISTORY:
1. Myelodysplastic syndrome, followed by Dr.
multiple PRBC transfusions
2. Atrial fibrillation Pacemaker (ECHO in , showed
Concentric LVH with EF 60%, Pulmonary hypertension with
estimated PA pressure of 50 mmHg, LAE, mild AR, mild TR)
4. Colon cancer resection ( )
5. Rosacea
6. chronic hyponatremia
7. T12 compression fracture
8. Frequent falls due to weakness, anemia, dehydration
## GENERAL:
pleasant, laying in bed in NAD, AOx3
## HEENT:
MM relatively moist, sclera anicteric, no conjuctival
pallor
## NECK:
no JVD, no LAD, supple
## CV:
Ns1s2, no MRG, irregular
## LUNGS:
CTAB, reduced air entry bibasally with exp wheeze
## ABDOMEN:
soft, NT,ND + BS
## EXT:
pulses +1 b/l in feet, trace pitting edema bilaterally, no
cyanosis
## NEURO:
moves all limbs, gait exam defered, CN grossly
intact
## GENERAL:
Pleasant, laying in bed in NAD, AOx3
## HEENT:
Flushed cheeks, MMM, sclera anicteric, no conjuctival
pallor
## NECK:
JVD at neck with pt supine, no LAD, supple, no
thryomegaly
## LUNGS:
CTA-bl, reduced air entry bibasally, dullness to
percussion at bases, scattered exp wheezes at bases
## ABDOMEN:
soft, NT,ND + BS
## EXT:
pulses +1 b/l in feet, trace pitting edema bilaterally, no
cyanosis. edema in UE R>L
## NEURO:
CNII-XII intact, strength in dital extremities,
sensation grossly intact, no asterixis, mild resting tremmor
## 2:40 PM SPUTUM SOURCE:
Expectorated.
GRAM STAIN (Final :
PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Final :
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
## BRIEF HOSPITAL COURSE:
male admitted from rehab after a recent admission for PNA
and septic shock, now presents with atrial fibrillation and
orthostatic hypotension.
## ACTIVE ISSUES:
# Orthostatic hypotension, likely secondary to atrial
fibrillation with rapid ventricular response in the 130's and
slight hypovolemia. An infectious workup including CXR, C. diff
PCR (had formed stool as well), UA, and blood cultures, was
negative. All outpatient antibiotics were stopped.
continued to have a non-productive cough, but remained afebrile
with a reassuring lung exam. The patient also underwent an ECHO
(please see results section for details), but compared to prior
study of , regional left ventricular systolic function
appears improved(now normal) and no evidence of valvular
abnormalities. For the orthostatic hypotension, the patient
was started on Midodrine 5mg TID and Fludrocortisone 0.1mg daily
with some improvement in the orthostatics. The patient further
improved once spontaneously converted to normal sinus rhythm.
The patient's amiodarone dosing was increased to 200mg daily
(and was discharged on that amount) with the hopes of keeping
him in sinus rhythm. was also given a unit of blood (has a
h/o MDS) per discussion with his hematologist after his Hct
dropped to 24.3 (on day of admission). His Hct was 27.0
after 1 unit of pRBC's. The patient continued to have
orthostatic hypotension, but to a much less extensive degree as
when was admitted. The patient is very deconditioned and
will need extensive rehab. should sit and stand slowly due
to this orthostatic hypotension, but should be encouraged to
participate in rehab.
# possible Hypothyroidism- The patient had a TSH of 8 at an OSH
and is on levothyroxine at 25mg po daily. However, the TSH
elevation may be related to acute illness. The thyroid function
test should be check within 1 month after discharge.
#. nutrition- The patient demonstrated poor PO intake during his
hospitalization. His albumin was 2.6. Per nutrition consult,
should be encourage to maintain adequate PO intake and should
continue on oral nutritional supplements (e.g Ensure Plus) BID
and daily multivitamin with minerals.
## # POSSIBLE COPD:
the patient exhibited mild wheezes
intermittently. was continued on tiotropium and nebs prn.
should have PFT's as an outpatient.
##
# MDS:
The patient was given 1 unit of pRBCs for Hct of
24.3(bumped to 27.0) and started on darbepoetin 40mcg every
thurday per discussion with the patient hematologist, Dr.
. The patient should follow up with Dr.
1 month of discharge.
## TRANSITION ISSUES:
- The patient should f/u with hematologist with 1 month of
discharge
- Please follow up repeat thyroid function tests within 1 month
of discharge
- Please follo up blood cultures pending from this admission.
- Please encourage adequate PO intake and oral nutrition
supplements (see above)
## MEDICATIONS ON ADMISSION:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Os-Cal 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral daily
3. Acetaminophen 1000 mg PO Q8H:PRN pain
4. Omeprazole 20 mg PO DAILY
5. Amiodarone 200 mg PO EVERY OTHER DAY
6. Amiodarone 100 mg PO EVERY OTHER DAY
7. Benzonatate 200 mg PO TID
8. darbepoetin alfa in polysorbat *NF* 40 mcg/0.4 mL Injection
weekly
9. Fluticasone Propionate NASAL 1 SPRY NU BID
10. Meladox *NF* (melatonin) 3 mg Oral daily
11. Doxycycline Hyclate 100 mg PO Q12H
12. Vancomycin Oral Liquid mg PO Q6H
13. Levothyroxine Sodium 12.5 mcg PO EVERY OTHER DAY
## DISCHARGE MEDICATIONS:
1. Midodrine 5 mg PO TID
2. Acetaminophen 1000 mg PO Q8H:PRN pain
3. Benzonatate 200 mg PO TID
4. darbepoetin alfa in polysorbat *NF* 40 mcg/0.4 mL Injection
weekly
5. Fluticasone Propionate NASAL 1 SPRY NU BID
6. Meladox *NF* (melatonin) 3 mg Oral daily
7. Multivitamins 1 TAB PO DAILY
8. Os-Cal 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral daily
9. Omeprazole 20 mg PO DAILY
10. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing
11. Diltiazem Extended-Release 120 mg PO DAILY
12. Amiodarone 200 mg PO DAILY
13. Levothyroxine Sodium 25 mcg PO EVERY OTHER DAY\
14. Fludrocortisone Acetate 0.1 mg PO DAILY
15. Multivitamins W/minerals 1 TAB PO DAILY
16. Ensure Plus *NF* (food supplement, lactose-free) 0.05-1.5
gram-kcal/mL Oral BID
## PRIMARY:
Orthostatic hypotension, Chronic Diastolic CHF with
exacerbation
## ACTIVITY STATUS:
Out of Bed with assistance to chair or
wheelchair.
## DISCHARGE INSTRUCTIONS:
Dear Mr. ,
It was a pleasure to participate in your care at . You were
amditted for nausea and were found to have low blood pressure
when standing. We determined that you do not have an infection
or bleeding. We started several new medication to increase your
blood pressure and made several medication changes. We also gave
you a transfusion of blood to help raise your blood pressure.
Please note your medication changes below.
Best Regards,
Your Medicine Team
| mimic | {"version": "mimic_iv", "note_type": "Discharge summary", "patient_id": "16462650", "visit_id": "21705935", "time": "2160-12-04 00:00:00"} |
15031111-RR-16 | 289 | ## INDICATION:
female with newly discovered a left lung mass,
presenting with persistent encephalopathy and right-sided weakness. Assess
for metastatic lesion.
## FINDINGS:
Please note, study is severely degraded by patient motion artifact. Within the
confines of the study, findings are as follows:
There is restricted diffusion within the left cerebellar hemisphere with
corresponding hyperintense T2/FLAIR signal changes (6:7), compatible with a
subacute infarction. It is difficult to assess the gradient echo images for
possible hemorrhage due to significant motion degradation. There is diffuse
parenchymal volume loss with commensurate prominence of the ventricles, sulci,
and cisterns. There are nonspecific hyperintense T2/FLAIR signal in changes
within the periventricular and subcortical white matter, which may be a
sequela of chronic small vessel microangiopathy. Within the confines of this
severely motion degraded study, there is no definite enhancing mass.
There is near complete opacification of the left maxillary sinus with
inspissation. The remaining paranasal sinuses appear clear. There is
opacification of bilateral mastoid air cells, left greater than right. The
visualized portions of the major intracranial flow voids are preserved.
## IMPRESSION:
1. Severely motion degraded study limiting evaluation.
2. Focal restricted diffusion within the left cerebellar hemisphere with
hyperintense T2/FLAIR signal abnormality compatible with a subacute
infarction. Suboptimal gradient echo images due to significant patient motion
artifact.
3. Within the limitations of this severely motion degraded study, no definite
evidence of an enhancing mass.
4. Opacification of bilateral mastoid air cells, may be related to infectious
or inflammatory condition ; correlate clinically. Near complete opacification
of the left maxillary sinus with inspissation.
## NOTIFICATION:
The findings were discussed with , M.D. by
, M.D. on the telephone on at 9:23 AM, 3
minutes after discovery of the findings.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "15031111", "visit_id": "27917559", "time": "2153-01-08 02:47:00"} |
12050128-RR-12 | 194 | ## HISTORY:
Seizure with subdural hemorrhage seen at outside hospital CT.
## FINDINGS:
There is an extra-axial hyperdense fluid collection along the
frontoparietal convexity measuring up to 2 mm in thickness with a small convex
component. 3- mm leftward shift of normally midline structures is noted. There
is no hydrocephalus, major vascular territory infarct, or intracranial mass.
The gray-white matter differentiation is preserved.
There is a non-displaced fracture of the right squamus temporal bone and a
longitudinally oriented fracture of the right petrous temporal bone involving
the auditory canal wall. There is mild opacification of the middle auditory
canal, likely represents blood. The visualized paranasal sinuses demonstrate
small retention cyst in the left sphenoid cell sinus.
When compared to the pior study, ther has been no significant changes.
## IMPRESSION:
1. Unchanged hyperdense extra-axial fluid collection along the right
frontoparietal convexity consistent with subdural hemorrhage; however, a small
component of epidural hemorrhage cannot be completely excluded, given
presence of fracture. Close followup is recommended.
2. Right parietal and squamus temporal bone fractures as described above.
3. Longitudinal right temporal fracture.
The findings were discussed with Dr. at the time of interpretation.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "12050128", "visit_id": "25505189", "time": "2156-03-02 09:02:00"} |
10790076-RR-14 | 106 | ## INDICATION:
female with history of primary biliary cirrhosis.
HCC surveillance.
## FINDINGS:
Note is again made of coarsened echotexture to the liver consistent
with patient's history of cirrhosis. No abnormal focal hepatic lesions are
seen. The main portal vein is patent and demonstrates hepatopetal flow.
There is no intra or extra-hepatic biliary ductal dilatation. A note is again
made of a small calculus abutting the fundus of the gallbladder. There is
recanalized paraumbilical vein. The spleen is enlarged measuring 19 cm.
Limited views of the kidneys demonstrate no abnormalities.
## IMPRESSION:
No suspicious focal hepatic lesions. Evidence of cirrhosis and
sequela of portal hypertension.
| mimic | {"version": "mimic_iv", "note_type": "Radiology", "patient_id": "10790076", "visit_id": "N/A", "time": "2162-08-01 14:37:00"} |
Subsets and Splits